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

You asked for reimbursement for Senna. 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 information provided does not include a receipt that shows a Senna prescription was paid for. It was unable to be ascertained that the receipt with Senna hand written on was for prescription Senna, as the prescription information was not submitted. The documentation was insufficient to determine if payment was made for a prescription drug ordered by a prescriber. We determined that the plan is not required reimburse the cost of Senna.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Letrozole prescribed for unknown diagnosis.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan provided documentation showing this claim was covered at the time of purchase for the plans cost share amount for a 60 day supply of the drug. We reviewed the plans Evidence of Coverage and determined the copay for up to a 60 day supply of a Tier 1 drug, purchased at a standard retail pharmacy is $16, which is the amount charged to you for the Letrozole. Copays are calculated on a per month basis, or 30 day supply per month. If you receive less than a 30 day supply, the amount is based on the cost per day. However, in this case the quantity you received was more than a 30 day supply and considered up to a 60 day supply. We have determined that the plan was correct in its calculation of the copay for the Letrozole and is not required to provide additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Saxenda 3 milligram/0.5 milliliter pen injector for weight loss. 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 determined that the plan is not required to cover Saxenda because it was prescribed for weight loss. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. It could not be determined if your plan does offers 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.A physician reviewed your appeal and determined that the plan is not required to cover Saxenda.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Fluvastatin 80-milligram Extended Release tablet to treat. The Part D plan denied the 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.We asked your prescriber to send us a prescriber statement, answers to prior authorization coverage criteria, and medical records. However, we did not receive the documentation.Fluvastatin is a generic drug on Tier 4 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 a prior authorization request for Hetlioz 20 milligram capsules prescribed for non-24 hour sleep/wake disorder. The Part D plan denied coverage.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 records submitted at the reconsideration level. We requested additional information from the prescriber. Specifically, we requested a prescriber statement to support the enrollee meets the plans prior authorization coverage criteria. However, we did not receive the requested information. The documentation provided does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Ciclopirox nail solution 8% prescribed for onychomycosis with lunula involvement. 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 the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication.  However, we did not receive the documentation.The documentation shows Ciclopirox was prescribed to treat onychomycosis with lunula involvement. 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 Ciclopirox.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a coverage request for Hydroxyzine HCL tablet 25 milligram prescribed for insomnia. 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 the enrollee's condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We received the documentation and included it in our review.The documentation shows your doctor prescribed Hydroxyzine HCL to treat insomnia. 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 Hydroxyzine HCL tablet 25 milligram prescribed for insomnia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% gel pump prescribed to treat hypogonadism. The Part D plan denied the appeal 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.Testosterone 1.62% gel pump is not included in the plans formulary (list of covered drugs). 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 prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm.A physician reviewed the appeal and determined that the plan is not required to cover Testosterone 1.62% gel pump.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed daily for primary osteoarthritis of the hand, lumbar intervertebral disc degeneration, and lumbar spondylosis. 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 doctor prescribed Lidocaine 5% patch to treat the enrollees primary osteoarthritis of the hand, lumbar intervertebral disc degeneration, and lumbar spondylosis. However, the Medicare approved compendia do not support the use of this drug, in this formulation, for these conditions. A physician reviewed the appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vraylar 3 milligram capsules prescribed as directed for bipolar 2 disorder. 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 enrollee does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plans coverage criteria and has not indicated why all alternatives required by the Plan would likely cause harm or not be as effective for the enrollee as the requested drug.  A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverageA physician reviewed your appeal and determined that the plan is not required to cover Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Daliresp 500-milligram tablet to treat chronic obstructive pulmonary disease. 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.We asked your prescriber to send us a prescriber statement, answers to prior authorization coverage criteria, and medical records. We received the documentation and included it in our review.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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% Patch to treat cervicalgia. 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.We asked your prescriber to send us a prescriber statement, answers to prior authorization coverage criteria, and medical records. However, we did not receive the documentation.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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methocarbamol 500-milligram tablet to treat low back pain, post laminectomy syndrome, not elsewhere specified, and radiculopathy lumbar region. 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 a prescriber statement, answers to off-formulary exception criteria, and medical records. We received a prescriber statement, answers to off-formulary exception criteria, and included it in our review. We did not receive medical records.In order to grant an exception for a drug not on the plans formulary, all 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Escitalopram tablet prescribed three per day. The Part D plan did not make a decision.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 enrollee purchased the Escitalopram on June 3, 2021. The records do not include a diagnosis and no medical records were provided by the prescriber to support a covered diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 reimburse Escitalopram.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 5 milligram tablets prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.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.Zolpidem Tartrate is a generic drug on Tier 2 of the plans formulary. There are no drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine VC syrup prescribed for nausea. 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 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 prescriber indicates Promethazine VC syrup is prescribed for nausea. We requested additional information from the prescriber for more specifics on the reported diagnosis but did not get a response. Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Promethazine VC syrup.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Cyanocobalamin 1000 microgram/milliliter prescribed for the treatment of malabsorption due to gastric bypass surgery. 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 fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Cyanocobalamin. There is no evidence the plan offers supplemental benefits for the Cyanocobalamin. This decision does not address 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 Adderall 10 milligram tablet.  At initial determination and redetermination the diagnosis of other amnesia was given. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication(s).  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.At reconsideration a diagnosis of Attention Deficit Disorder was given. No medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Adderall.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cinacalcet Hydrochloride 30 milligram tablet prescribed daily for secondary hyperparathyroidism due to chronic kidney disease in patients not on dialysis. 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 doctor prescribed Cinacalcet Hydrochloride to treat the enrollees secondary hyperparathyroidism due to chronic kidney disease. The enrollee is not on dialysis. The Medicare approved compendia do not support the use of this drug for hyperparathyroidism due to chronic kidney disease in patients not on dialysis. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules. A physician reviewed the appeal and determined that the plan is not required to cover Cinacalcet Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 90 milligram tablet to treat hypothyroidism. The Part D plan denied the 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.Non - Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone Acetaminophen 5 milligram-325 milligram tablets prescribed for moderate neck pain. The plan denied the appeal as the plan imposed a restriction of opioid medication.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 indicates the enrollee has been denied access to opioid medication by the plan. We asked the prescriber to send us a prescriber statement to indicate the enrollee meets the plans case management criteria for coverage. However, we did not receive the requested documentation.A physician reviewed your appeal and determined you are considered at-risk and the plan is not required to cover the drug at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rituxan 100 milligram/10-milliliter injectable prescribed as directed for immune complex mediated glomerulonephritis. 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 Rituxan to treat your immune complex mediated glomerulonephritis. However, the Medicare approved compendia do not support the use of this drug for your condition. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules.A physician reviewed your appeal and determined that the plan is not required to cover Rituxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed for fracture of unspecified part of neck of left femur, osteoarthritis of left knee, and pain in low back. 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 this medication was needed. We did not receive the documentation requested.The medical records show the doctor prescribed Lidocaine 5% patch to treat the enrollees fracture of unspecified part of neck of left femur, osteoarthritis of left knee, and pain in low back. 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 Lidocaine 5% patch. 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 Amantadine 100 milligram capsules prescribed for drug induced dyskinesia while taking levodopa for Parkinson's disease. The Part D plan denied the request for a tiering exception.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.Amantadine is a generic drug on Tier 4 of the plans formulary. The prescriber submitted a supporting statement. The supporting statement did not address why the drug available on a lower tier of the plans formulary (amantadine solution 50mg/5ml - Tier 3) would not work. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tretinoin cream 0.05 percent prescribed as directed for acne rosacea. 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 Tretinoin cream to treat your acne rosacea. 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 acne rosacea.