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

At issue is a direct member reimbursement request for Estradiol 1 milligram tablets. 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 submitted documentation does not include medical records to support a covered diagnosis. A request for information was sent to the prescriber; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for Estradiol 2 milligram tablets. 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 submitted documentation does not include medical records to support a covered diagnosis. A request for information was sent to the prescriber; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for Pregabalin 75 milligram capsules. 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 submitted documentation does not include medical records to support a covered diagnosis. A request for information was sent to the prescriber; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for Progesterone 100 milligram capsules. 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 submitted documentation does not include medical records to support a covered diagnosis. A request for information was sent to the prescriber; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for Progesterone 200 milligram capsules. 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 submitted documentation does not include medical records to support a covered diagnosis. A request for information was sent to the prescriber; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed for rheumatoid arthritis and fibromyalgia pain. The case was auto-forwarded by the plan.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 submitted documentation indicates the prescriber ordered Cyclobenzaprine Hydrochloride for rheumatoid arthritis and fibromyalgia pain. The Medicare approved compendia do not support the use of the drug at issue for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Buproprion HCL 100 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 record shows Buproprion HCL was given as a self administered drug to the enrollee while inpatient in the hospital emergency room. The National Drug Code 60687-0351-01 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Buproprion HCL. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Famotipine 20 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 record shows Famotipine was given as a self administered drug to the enrollee while inpatient in the hospital emergency room. The National Drug Code 50268-0303-15 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Famotipine. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Fish Oil 1000 MEQ softgel prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 record shows Fish Oil was given as a self administered drug to the enrollee while inpatient in the hospital emergency room. The National Drug Code 77333-0308-10 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Fish oil. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Hydrocodone-Acetaminophen 5/325 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 record shows Hydrocodone-Acetaminophen was given as a self administered drug to the enrollee while inpatient in the hospital emergency room. The National Drug Code 00904-6824-61 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Hydrocodone-Acetaminophen. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Levothyroxine 75 microgram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 record shows Levothyroxine was given as a self administered drug to the enrollee while inpatient in the hospital emergency room. The National Drug Code 51079-0441-20 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Levothyroxine. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Metoprolol Tartrate 100 milligram tablet prescribed unknown diagnosis. The Part D plan denied the enrollees 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 record shows Metoprolol Tartrate was given as a self administered drug to the enrollee while inpatient in the hospital emergency room. The National Drug Code 62584-0267-01 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Metoprolol Tartrate. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Montelukast Sodium 10 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 record shows Montelukast Sodium was given as a self administered drug to the enrollee while inpatient in the hospital emergency room. The National Drug Code 00904-6808-61 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Montelukast Sodium. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Oxybutynin 5 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 record shows Oxybutynin was given as a self administered drug to the enrollee while inpatient in the hospital emergency room. The National Drug Code 68084-0400-01 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Oxybutynin. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Pantoprazole 20 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 record shows Pantoprazole was given as a self administered drug to the enrollee while inpatient in the hospital emergency room. The National Drug Code 50268-0636-15 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Pantoprazole. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Potassium CL ER 20 MEQ tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 record shows Potassium CL ER was given as a self administered drug to the enrollee while inpatient in the hospital emergency room. The National Drug Code 68084-0360-09 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Potassium CL ER. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Pravastatin 20 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 record shows Pravastatin was given as a self administered drug to the enrollee while inpatient in the hospital emergency room. The National Drug Code 60687-0178-01 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Pravastatin. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Rifampin 150 milligram capsule prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 record shows Rifampin was given as a self administered drug to the enrollee while inpatient in the hospital emergency room. The National Drug Code 68084-0357-21 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Rifampin. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Venlafaxine 25 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 record shows Venlafaxine was given as a self administered drug to the enrollee while inpatient in the hospital emergency room. The National Drug Code 68084-0896-25 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Venlafaxine. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Venlafaxine 75 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 record shows Venlafaxine was given as a self administered drug to the enrollee while inpatient in the hospital emergency room. The National Drug Code 68084-0856-01 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Venlafaxine. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cresemba 186 milligram capsules. The Part D plan denied the request for coverage. 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 documentation indicates that Cresemba has been prescribed prophylactically to avoid fungal infection due to the enrollees high risk for infection, as the enrollee has graft versus host disease of the liver and is currently on immunosuppressive therapy. It is also noted that the enrollee has myelodysplastic syndrome and blastic plasmacytoid dendritic cell neoplasm and has undergone an allogeneic stem cell transplant in 2019. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for Ciprofloxacin Hydrochloride 500 milligram tablet prescribed twice daily for unknown diagnosis. 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. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested.A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  Without a diagnosis, it cannot be established that the requested drug 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 the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium Citrate-Citric Acid solution. 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.We determined that the plan is not required to cover Potassium Citrate-Citric Acid because it is an over-the-counter drug. Nonprescription or over-the-counter drugs are excluded from coverage. The enrollees plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20 milligram tablet prescribed three times daily for pulmonary hypertension. 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 records submitted at the reconsideration level. The medical records support the doctor prescribed Sildenafil to treat the enrollees pulmonary hypertension. The 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 enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Sildenafil. A diagnosis of pulmonary hypertension must be confirmed with a heart catheterization. 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

At issue is Viibryd 20 milligram tablet prescribed 1 12 tablets daily for generalized anxiety disorder. 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 documentation shows the enrollees doctor prescribed Viibryd to treat generalized anxiety disorder. However, the Medicare approved compendia do not support the use of the requested drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Viibryd.