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

At issue is a request for coverage of Lidocaine 5% patches. 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 Lidocaine 5% patches have been prescribed for chronic left lateral hip pain due to an acetabular labral tear, hip sprain, trochanteric bursitis, and tendonitis. 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 Lidocaine 5% patches.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prednisone 5 milligram tablets. 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 requested documentation.You requested Prednisone 5 milligram tablets. The plan denied your request stating that the requested drug was not covered under the Part D plan. However, there were no medical records submitted supporting your condition. The QIC is unable to determine if your condition is a medically accepted indication to support the use of the requested drug.A physician reviewed your appeal and determined that the plan is not required to cover Prednisone 5 milligram tablets.
Appeal type: Prescription Drug
Decision: Favorable

You requested reimbursement for Shingrix vial kit. The request was not routed timely and not received by the appropriate department. 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 paid for a Shingrix vial kit and administration cost for the vaccine.We determined that the plan is required to reimburse you for the Shingrix vial kit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Morphine Sulfate extended release 60-milligram tablet (60 tablets per 30 days) for an unknown diagnosis. The Part D plan denied your request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The documentation shows your doctor prescribed Morphine for an unknown diagnosis. 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 your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan tablet 550 milligram prescribed for small intestinal bacterial overgrowth and irritable bowel syndrome with diarrhea. 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 medical records to support a diagnosis, it cannot be established that the Xifaxan is being prescribed for a medically accepted indication. As such, Xifaxan 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 25 milligram extended-release oral tablet. 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.Myrbetriq is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. 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: Favorable

You requested Breo Ellipta 200-25 milligram inhaler prescribed for chronic obstructive pulmonary disease. The Part D plan denied your request for reimbursement. 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 Breo Ellipta was billed as a self-administrable drug during an outpatient observation stay. The hospital invoice submitted shows the hospital was reimbursed for the medication. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Breo Ellipta is indicated for the long-term maintenance treatment of chronic obstructive pulmonary disease.'A physician reviewed your appeal and determined that the plan is not required to cover Breo Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Amoxicillin/Clavulanate Potassium 875-125 milligram tablets. The case was auto-forwarded by 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 submitted documentation does not include medical records to support a prescribed diagnosis. A request for information was sent to your prescriber; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, reimbursement cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Morphine 10 milligram/10-milliliter vial prescribed 10 vials per 30 days for unknown diagnosis. The Part D plan denied your request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The documentation shows your doctor prescribed Morphine for an unknown diagnosis. 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 your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Digoxin 125 microgram tablet prescribed for an unknown diagnosis. 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 the plan reprocessed claims for the Digoxin 125 microgram tablet and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diltiazem XR 120 milligram tablet prescribed for an unknown diagnosis. 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 the plan reprocessed claims for the Diltiazem XR 120 milligram tablet and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Glimepiride 4 milligram tablet prescribed for an unknown diagnosis. 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 the plan reprocessed claims for the Glimepiride 4 milligram tablet and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lisinopril 10 milligram tablet prescribed for an unknown diagnosis. 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 the plan reprocessed claims for the Lisinopril 10 milligram tablet and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Metformin Hydrochloride 1000 milligram tablet prescribed for an unknown diagnosis. 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 the plan reprocessed claims for the Metformin Hydrochloride 1000 milligram tablet and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Myrbetriq ER 50 milligram tablet prescribed for an unknown diagnosis. 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 the plan reprocessed claims for the Myrbetriq ER 50 milligram tablet and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Terconazole 0.4% cream prescribed for an unknown diagnosis. 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 the plan reprocessed claims for the Terconazole 0.4% cream and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tramadol Hydrochloride 50 milligram tablet prescribed for an unknown diagnosis. 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 the plan reprocessed claims for the Tramadol Hydrochloride and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone Cypionate 200 milligram prescribed for an unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. 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 your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 25 milligram tablets 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.Myrbetriq ER is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. 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 Desvenlafaxine 100 milligram tablets. 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.The submitted documentation did not include medical records or a supporting statement. A request for information was sent to your physician. Medical records and a supporting statement were not received. Therefore, 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

You requested Freestyle Lite Test Strip prescribed for 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 determined that the plan is not required to cover or reimburse you for the Freestyle Lite Test Strip because it is not considered a medical supply directly associated with the injection of insulin. Although, this supply is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. This decision does not address the medical necessity or appropriateness of the supply. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gammagard solution 20 grams/200 milliliter prescribed every week for autoimmune gastrointestinal dysmotility. 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Gammagard to treat your autoimmune gastrointestinal dysmotility. 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 enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Gammagard. There is no indication that you have a qualifying diagnosis. 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 Zelnorm 6 milligram tablets prescribed for small intestinal bacterial overgrowth. 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.Medicare does not allow Part D drug plans to cover drugs produced by a manufacturer that does not participate in the Medicare Gap Discount Program. The Centers for Medicare & Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. Records show that the manufacturer, AlfaSigma, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Payment cannot be allowed for a drug whose manufacturer does not participate in the Medicare Gap Discount Program.We determined that the plan is not required to cover the drug at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cholestyramine packet prescribed for an 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. The record shows the plan reprocessed your claim for the Cholestyramine packet and adjusted the amount owed due to a change in your low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because according to Medicare records, you did not qualify for low income subsidy copay level when this drug was purchased. The plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its recalculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 90 milligram-103 milligram tablet. 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. Entresto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. 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 Fosteum 27/20/200 milligram-unit, 180 per 90 days 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, drugs that are considered a medical food are excluded from coverage under Part D. Fosteum is on Medicares excluded list of drugs because it is considered a medical food. Therefore, we determined that the Part D plan is not required to cover the Fosteum. 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 Topamax 200 milligram tablet prescribed twice daily. 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 provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. 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.