Persius/hicric huggingface dataset:
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Tadalafil 5 milligram tablets prescribed for benign prostatic hyperplasia. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Tadalafil is a non-formulary drug. Non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cutaquig 16.5% (2 grams/12 milliliter) intravenous solution prescribed for selective deficiency of immunoglobulin G. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The Cutaquiq at issue is prescribed for intravenous immunoglobulin therapy in the enrollees home. This is eligible for coverage under Part B. Cutaquig is not eligible for Part D coverage.We determined that the plan is not required to cover Cutaquig.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Travatan Z 0.004% ophthalmic solution prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is not included on your plans formulary. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

You requested Montelukast Sodium 10 milligram tablet prescribed daily for allergic rhinitis. The Part D plan denied your reimbursement request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. You asked your prescriber to send us information regarding your condition. You also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.Your medical records show your doctor prescribed Montelukast Sodium to treat your allergic rhinitis. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Montelukast Sodium is indicated for the treatment of allergic rhinitis.A physician reviewed your appeal and determined that the plan is required to reimburse Montelukast Sodium. A valid proof of payment and medical necessity has been established.
Appeal type: Prescription Drug
Decision: Favorable

You requested Pantoprazole Sodium 40 milligram prescribed for unknown diagnosis. The Part D plan denied your request reimbursement request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. You asked your prescriber to send us information regarding your condition. You also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.Your medical records show your doctor prescribed Pantoprazole Sodium to treat your gastroesophageal reflux disease. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Pantoprazole Sodium is indicated for the treatment of gastroesophageal reflux disease.A physician reviewed your appeal and determined that the plan is required to reimburse Pantoprazole Sodium. A valid proof of payment and medical necessity has been established.
Appeal type: Prescription Drug
Decision: Favorable

You requested Metoprolol Succinate 50 milligram prescribed for hypertension. The Part D plan denied your request reimbursement request..We received the case to perform an independent and de novo review. We reviewed all documentation submitted. You asked your prescriber to send us information regarding your condition. You also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.Your medical records show your doctor prescribed Metoprolol Succinate to treat your tinea cruris. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Metoprolol Succinate is indicated for the treatment of hypertension.A physician reviewed your appeal and determined that the plan is required to reimburse Metoprolol Succinate. A valid proof payment and medical necessity has been established.
Appeal type: Prescription Drug
Decision: Favorable

You requested Colesevelam Hydrochloride 5 milligram prescribed for mixed hyperlipdemia. The Part D plan denied your request reimbursement request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. You asked your prescriber to send us information regarding your condition. You also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.Your medical records show your doctor prescribed Colesevelam Hydrochloride to treat your osteoarthritis. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Colesevelam Hydrochloride is indicated for the treatment of mixed dyslipidemia.A physician reviewed your appeal and determined that the plan is required to reimburse Colesevelam Hydrochloride. A valid proof payment and medical necessity has been established.
Appeal type: Prescription Drug
Decision: Favorable

You requested Fenofibrate 160 milligram prescribed for mixed dyslipidemia. The Part D plan denied your request reimbursement request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. You asked your prescriber to send us information regarding your condition. You also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.Your medical records show your doctor prescribed Fenofibrate to treat your mixed dyslipidemia. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Fenofibrate is indicated for the treatment of mixed dyslipidemia.A physician reviewed your appeal and determined that the plan is required to reimburse Fenofibrate. A valid proof of payment and medical necessity has been established.
Appeal type: Prescription Drug
Decision: Favorable

You requested Celebrex 200 milligram prescribed for osteoarthritis. The Part D plan denied your request reimbursement request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. You asked your prescriber to send us information regarding your condition. You also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.Your medical records show your doctor prescribed Celebrex to treat your osteoarthritis. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Celebrex is indicated for the treatment of osteoarthritis.A physician reviewed your appeal and determined that the plan is required to reimburse Celebrex. A valid proof of payment and medical necessity has been established.
Appeal type: Prescription Drug
Decision: Favorable

You requested Risperdal 1 milligram prescribed daily for schizophrenia. The Part D plan denied your reimbursement request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. You asked your prescriber to send us information regarding your condition. You also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.Your medical records show your doctor prescribed Risperdal to treat your schizophrenia. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Risperdal is indicated for the treatment of schizophrenia.A physician reviewed your appeal and determined that the plan is required to reimburse Risperdal. A valid proof of payment and medical necessity has been established.
Appeal type: Prescription Drug
Decision: Favorable

You requested Ketoconazole 2% cream prescribed for tinea cruris. The Part D plan denied your request reimbursement request..We received the case to perform an independent and de novo review. We reviewed all documentation submitted. You asked your prescriber to send us information regarding your condition. You also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.Your medical records show your doctor prescribed Ketoconazole to treat your tinea cruris. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: 'Ketoconazole cream 2% is indicated for tinea corporis, tinea cruris and tinea pedis caused by Trichophyton rubrum, T mentagrophytes, and Epidermophyton floccosum.'A physician reviewed your appeal and determined that the plan is required to reimburse Ketoconazole. A valid proof of payment and medical necessity has been established.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Finasteride 5 milligram prescribed one tablet daily for enlarged prostate. The Part D plan denied your request reimbursement request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. You asked your prescriber to send us information regarding your condition. You also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to reimburse Finasteride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pravastatin 40 milligram prescribed one tablet daily for hyperlipidemia. The Part D plan denied your request reimbursement request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. You asked your prescriber to send us information regarding your condition. You also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to reimburse Pravastatin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Metaxalone 800 milligram prescribed one table three times a day for musculoskeletal pain. The Part D plan denied your request reimbursement request..We received the case to perform an independent and de novo review. We reviewed all documentation submitted. You asked your prescriber to send us information regarding your condition. You also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to reimburse Metaxalone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Alcohol 62% antiseptic (Noxin popswab) for unknown diagnosis.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to reimburse you for the Alcohol Antiseptic.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Allegra D 24 hour 60 milligram tablet for unknown diagnosis.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to reimburse you for the Allegra D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azulfidine 500 milligram prescribed four times a day for unknown diagnosis. The Part D plan denied your request reimbursement request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. You asked your prescriber to send us information regarding your condition. You also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.The documentation includes a proof of payment. However, the documentation shows your doctor prescribed Azulfidine to treat an unknown condition. The Medicare approved compendia do not support the use of this drug for any of the conditions listed. A physician reviewed your appeal and determined that the plan is not required to reimburse the Azulfidine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dicyclomine 10 milligram capsule prescribed 2 capsules twice daily for unknown diagnosis. The Part D plan denied your reimbursement request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. You asked your prescriber to send us information regarding your condition. You also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.The documentation includes a proof of payment. However, the documentation shows your doctor prescribed Dicyclomine to treat an unknown condition. The Medicare approved compendia do not support the use of this drug for any of the conditions listed. A physician reviewed your appeal and determined that the plan is not required to reimburse the Dicyclomine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Flonase 0.5% spray for unknown diagnosis.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to reimburse you for the Flonase.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Celebrex 200 milligram capsules prescribed to treat low back pain. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you.A physician reviewed your appeal and determined that the plan is not required to cover Celebrex 200 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone gel 1.62% for an unknown diagnosis. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation. Without a diagnosis, it cannot be established that Testosterone is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Testosterone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuedexta 20-10 milligram capsule prescribed for pseudobulbar affect. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your medical records show your doctor prescribed Nuedexta 20-10 milligram capsule to treat your pseudobulbar affect. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the plan's coverage criteria have been satisfied.A physician reviewed your appeal and determined that the plan is not required to cover Nuedexta 20-10 milligram capsule. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Modafinil 200 milligram tablet prescribed three time daily for idiopathic hypersomnia. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Modafinil to treat your idiopathic hypersomnia. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Desloratadine 5 milligram tablets to treat allergic rhinitis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Desloratadine is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levalbuterol Hydrochloride 1.25 milligrams per 3 milliter nebulizer solution prescribed three times daily for exacerbation of chronic obstructive pulmonary disease and asthma. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows Levalbuterol Hydrochloride is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Levalbuterol Hydrochloride. Please submit your request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 75-milligram capsule to treat chronic bilateral low back pain without sciatica. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sucralfate suspension 1 gram/milliliter for an unknown diagnosis. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.Without a diagnosis, it cannot be established that Sucralfate is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover Sulcralfate.A physician reviewed your appeal and determined that the plan is not required to cover Sucralfate.