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

At issue is Pregabalin 150 milligrams prescribed as directed to treat your condition while in a hospital setting. The Part D plan denied the request for additional reimbursement. We received an auto-forwarded request from the plan to reconsider the appeal. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The record shows you received the drug while in the hospital. You submitted documentation to the plan that includes a copy of an itemized hospital bill. However, the record does not include proof of payment for the drug requested.We determined that the plan is not required to reimburse you for the Pregabalin. The plan calculates reimbursement based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the out-of-network pharmacy (i.e., hospital) charged you. The plan is not required to reimburse you without a statement including proof of payment for the drugs indicated on the hospital bill.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets prescribed twice daily for paroxysmal atrial fibrillation. The Part D plan denied your request for a tiering exception. We received a reconsideration 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. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. 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

You requested coverage for Zolpidem Tartrate 12.5 microgram tablets prescribed for insomnia. The Part D plan denied your request for a formulary exception. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Zolpidem Tartrate to treat your insomnia. The Medicare approved compendia support the use of this drug for your condition. However, the plan formulary includes other drugs that could be used to treat your condition. Your records do not show that any alternative drugs on the plan formulary have been tried or why you cannot take them. This decision does not address the medical necessity of the requested drug. It only means that it cannot grant a formulary exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Megestrol Acetate 40 milligrams prescribed daily for poor appetite and weight loss. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization requirements be met before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration 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. Your medical records show your doctor prescribed Megestrol Acetate to treat your poor appetite and weight loss. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.A physician reviewed your appeal and determined that the plan is not required to cover Megestrol Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Actemra ACT Pen injector 162 milligrams per 0.9 milliliters to treat panuveitis with cystoid macular edema. The Part D plan denied the request stating that the provided diagnosis is not a medically accepted indication. We received a reconsideration 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 record shows you were prescribed Actemra ACT Pen injector for recalcitrant panuveitis. We asked your doctor to send us a supporting statement to show why Actemra ACT Pen injector is medically necessary for you. No additional documentation was received.In review of the Medicare approved compendia, recalcitrant panuveitis is not a medically accepted indication for Actemra ACT Pen injector. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Actemra ACT Pen injector at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Crinone 4 percent gel prescribed as directed for menopausal and postmenopausal disorders, atrophic vaginitis, menopausal depression, and insomnia. The Part D plan denied your request for a formulary exception because the drug was not prescribed for a medically accepted indication. We received a reconsideration 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Crinone 4 percent gel to treat your menopausal and postmenopausal disorders, atrophic vaginitis, menopausal depression, and insomnia. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and determined  that the plan is not required to cover Crinone 4 percent gel because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clodan 0.05% shampoo prescribed for telogen effluvium. You requested that the plan provide coverage for an off-formulary drug. The plan did not make a decision within the required timeframe. We received an auto-forwarded reconsideration request from the plan.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 documentation shows the doctor prescribed Clodan shampoo for telogen effluvium. However, the Medicare approved compendia do not support the use of Clodan for this condition. Therefore, the request for a formulary exception cannot be considered.A physician reviewed your appeal and determined that the plan is not required to cover Clodan shampoo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nystatin-Triamcinolone Acetonide 100,000 unit per gram 0.1% topical cream for other specified diseases of the anus and rectum and rash and other nonspecific skin eruption. The Part D plan denied the request stating that the diagnosis is not a medically accepted indication. We received an expedited reconsideration 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 prescriber stated the enrollee does have perianal candidiasis. However, this is not supported by the medical records. The Medicare approved compendia do not support the use of the drug for the enrollees condition. Therefore, the 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Flovent HFA 110 milligram inhaler prescribed twice daily for chronic sinus disease and allergies. The Part D plan denied the tiering request. We received a reconsideration 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.Flovent HFA 110 milligram inhaler is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. 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

You requested Otezla 30 milligram tablet prescribed twice daily for atopic dermatitis. The Part D plan denied the request because it does not meet the criteria of a medically accepted indication. We received a reconsideration 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 record shows you were prescribed Otezla to treat atopic dermatitis. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Otezla because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zioptan, 0.0015% eye drops prescribed for glaucoma. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration 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. A physician reviewed your appeal and determined that the plan is not required to cover the Zioptan as an off-formulary exception.The submitted documentation shows that the drug was prescribed to treat the enrollees glaucoma. The Medicare approved compendia support the use of the requested drug for this condition. Additionally, it is noted that the enrollee is allergic to preservatives and requires preservative-free eye drops. The plans formulary lists two preservative-free eyes drops used to treat glaucoma. The documentation does not sufficiently address why the preservative-free alternative eye drops listed in the plans formulary have not been tried, or are contraindicated. Therefore, the plan will not cover the Zioptan as an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tadalafil 20 milligram tablets prescribed as directed for erectile dysfunction. The Part D plan denied your request because drugs being used for the treatment of erectile dysfunction are excluded from coverage by Medicare Part D. We received a reconsideration request. We performed and 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 determined that the plan is not required to cover Tadalafil. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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 Aimovig 140 milligram injection prescribed twice a month for prophylactic treatment for migraines. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.You do not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria.  Namely, the prior authorization requires you to have had four or more migraines per month prior to starting migraine-preventive medications and there are no medical records to support you have tried and failed at least two different medication classes that are used to prevent migraines. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxistat 1 percent topical cream prescribed as directed for L30.1, Dyshidrosis [pompholyx]. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication and the documentation does not support an off-formulary exception. We received an auto-forwarded reconsideration request from the plan. We performed and 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 also researched Medicare systems and reviewed the enrollment data available.We asked your prescriber to send us information regarding your condition. We also asked for a prescribers statement and medical records to show why you need this medication. We received the prescribers statement and included it in our review. However, we did not receive your medical records. The prescriber initially provided the diagnosis of dyshidrosis pompholyx. In the request for reconsideration, the prescriber changed the diagnosis to tinea corporis. The case file does not include any medical records to support a diagnosis of tinea corporis. The use of the requested drug to treat dyshidrosis pompholyx is not a medically accepted indication. The Medicare approved compendia do not support the use of this drug for your condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.In addition, the records do not show why you cannot take other drugs on your plans formulary for your condition. Specifically, your physician submitted a prescriber statement that does not indicate you have tried any alternative drugs to treat your condition. The records submitted do not show all alternative drugs on the plan formulary have been tried or why you cannot take them. Therefore, the plan is not required to grant an off-formulary exception for the Oxistat 1 percent topical cream.A physician reviewed your appeal and determined that the plan is not required to cover Oxistat 1 percent topical cream.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent patch prescribed as needed for back pain. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received a reconsideration 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. We also researched Medicare systems and reviewed the enrollment data available. The prescriber submitted a supporting statement at reconsideration. This prescribers statement shows the enrollee was prescribed Lidocaine 5 percent patch to treat postherpetic neuralgia. However, the prescriber statement submitted to the plan lists a diagnosis of back pain and medical records were not submitted to corroborate the diagnoses reported. The Medicare approved compendia do not support the use of this drug for your condition. There is insufficient documentation to establish medical necessity. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5 percent patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyzulta 0.024% ophthalmic solution prescribed to treat glaucoma. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration 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 documentation shows you have tried some of the formulary alternatives. However, the records do not show why you cannot take other drugs on the plans formulary for your condition. A physician reviewed your appeal and determined that the plan is not required to cover the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tobramycin, 300 milligrams per 5 milliliter vials via nebulizer for the treatment of chronic obstructive pulmonary disease with acute exacerbation; centrilobular emphysema; and COVID-19. The Part D plan denied the request because the Part D plan stated that drugs eligible for coverage under Medicare Part B were not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received a reconsideration 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. A physician reviewed your appeal and determined that the plan is not required to cover the Tobramycin because the conditions noted above are not medically accepted indications to use this drug.The requested drug does not meet the definition of a Medicare Part D drug and is therefore not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Reclast 5 milligrams/100 milliliters prescribed annually for postmenopausal osteoporosis. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received a reconsideration 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 record shows Reclast is being prescribed to treat the enrollees postmenopausal osteoporosis. However, this drug is eligible for coverage under Medicare Part B. We determined that the plan is not required to cover Reclast 5 milligrams/100 milliliters.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nadolol 20 milligram tablets prescribed for hypertension and the prevention of migraines. The Part D Plan denied your request for a tiering exception because the documentation did not support why alternative drugs in a lower tier could not be used for this enrollee. We received a reconsideration 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. Nadolol is a generic drug on Tier 3 of the plans formulary. The doctor submitted a supporting statement. The statement said the enrollee could not tolerate two other medications from the plans formulary. However, the plans formulary includes medications in the same class as Nadolol, on lower tiers. The doctor did not address why all alternative medications would not work for this enrollee. All generic drugs on lower tiers have not been tried. Therefore, this drug is 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 Spiriva Respimat 2.5 micrograms prescribed as directed for tracheobronchomalacia. The Part D plan denied the request because it does not meet the criteria of a medically accepted indication. We received a reconsideration 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 record shows you were prescribed Spiriva Respimat to treat your condition. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Spiriva Respimat because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Leflunomide 10 milligram tablets prescribed daily for seropositive erosive rheumatoid arthritis. The Part D Plan denied your request for a tiering exception because the documentation did not support why alternative drugs in a lower tier could not be used for this enrollee. We received a reconsideration 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. Leflunomide is a generic drug on Tier 3 of the plans formulary. The doctor submitted a supporting statement. The statement said the enrollee is stable on Leflunomide. However, the plans formulary includes other medications, which are the same class as Leflunomide, on lower tiers. The doctor did not address why all available drugs in the same class would not work for the enrollee. All generic drugs on lower tiers have not been tried. Therefore, this drug is 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.