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

At issue is Capecitabine, 500 milligram tablets prescribed for primary left-sided breast cancer with liver, lung, and bone metastases. The Part D plan denied the request because drugs that can be covered under Medicare Part B are not eligible to be covered under the Medicare Part D prescription drug benefit. We received an expedited request from the appellant to reconsider the appeal.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. According to Medicare rules, a drug prescribed for a Part D eligible individual cannot be considered a covered Part D drug if payment for the drug is available under Medicare Part A or B for that individual. Oral self-administered versions of covered cancer drugs may be paid by Medicare Part B if other coverage requirements are met. We determined that the Capecitabine is eligible for coverage under Medicare Part B. Therefore, the Part D plan is not required to cover the drug. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitriol 0.25 micrograms prescribed daily for secondary hypocalcemia in an enrollee with chronic kidney disease. The Part D plan denied the request because drugs that could be covered under Part B are not eligible to be covered under the Part D Drug benefit. 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 record shows the enrollee received a kidney transplant on July 1, 2018. However, the evidence shows the transplant failed on July 9, 2018, and dialysis resumed on this date. Therefore, this drug is eligible for coverage under Medicare Part B.We determined that the plan is not required to cover Calcitriol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcipotriene ointment 0.005% to treat pre-cancerous skin lesions. The Part D plan denied the request stating that the provided diagnosis is a non-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 documentation does not satisfy the plans 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 as the requested drug. 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 tiering exception request for Fluorouracil 5% to treat your condition. 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.Fluorouracil 5% is a generic drug on tier 4 of the plans formulary. There are no generic 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

At issue is Eliquis 5 milligram tablet prescribed twice daily for other pulmonary embolism. 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. The prescriber statement shows no other drugs have been used for this condition. 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

At issue is the Boostrix vaccine administered as a prophylaxis during an appointment at a physicians office. The Part D plan denied the request for reimbursement. We received an auto-forwarded 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.The record shows you received the vaccine during a physical appointment with your physician. However, the record does not include an itemized proof of payment for the drug requested.We determined that the plan is not required to reimburse you for the vaccine. 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 bill.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eszopiclone 1 milligram tablet prescribed for insomnia. 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.The prescriber has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxychloroquine Sulfate 200 milligrams tablet. The Part D plan denied your request for a reimbursement. We received a reconsideration request from the plan. 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 documentation shows that you were in the deductible stage when Hydroxychloroquine Sulfate tablets were purchased on November 04, 2020, for the amount of 69.00 dollars. When the enrollee has not met their deductible, coverage cannot be allowed as defined by Medicare rules. Once the enrollee has met the deductible amount, the enrollee moves into the initial coverage stage. An enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. Therefore, the plan is not required to provide reimbursement for the Hydroxychloroquine Sulfate received on November 04, 2020.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement of the cost of Penicillin VK 500 milligram tablets. The Part D plan did not provide a timely redetermination decision. 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 regulations and Medicare approved compendia. The plan covers a prescription at an out-of-network pharmacy only if you cant get the covered drug because there are no open in-network pharmacies within a reasonable driving distance, your prescription is for a specialty drug that was not available at the in-network pharmacy, you were eligible for Medicaid but not enrolled yet, or you were evacuated from your home because of an emergency and do not have access to an in-network pharmacy. You indicated that you went to a pharmacy that was not affiliated with the plan and are seeking reimbursement for Penicillin VK 500 milligram tablets purchased on December 3, 2020 for $38.65. The requirements were not met as stated above. Therefore, it is ineligible for reimbursement.   A physician reviewed your appeal and determined that the plan is not required to reimburse the cost of Penicillin VK 500 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 20 milligrams prescribed as directed to treat your condition. 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 from your pharmacy. 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 Xarelto. 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. The plan is not required to reimburse you without a statement including proof of payment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is the Shingrix vaccination. The Part D plan denied coverage because the total amount paid was the enrollees copayment amount. 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. In this instance, it has been determined that reimbursement cannot be allowed for the vaccination at issue, as the enrollee was in the crossover coverage stage of the Part D benefit. The enrollee went from the Yearly Deductible Stage to the Initial Coverage Stage and was billed under both coverage stages. The approved cost of medication was $182.27. The enrollee was charged $161.51 in the Yearly Deductible Stage. $161.51 was the amount left needed to satisfy the yearly deductible. $20.76 was the accumulated amount in the initial coverage stage. The enrollee was charged $20.76 in the Initial Coverage Stage. $161.51 plus $20.76 equals $182.27 (the enrollees copayment).
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 1% Gel was prescribed for adverse effect of nonsteroidal anti-inflammatory drugs. 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. The prescriber has not sufficiently addressed the plans coverage criteria, as your osteoarthritis pain in joints susceptible to topical treatment such as feet, ankles, knees, hands, wrists, or elbows was not confirmed.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 Zeposia 0.92 milligram capsules to treat multiple sclerosis. 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 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 has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewers opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Incruse Ellipta Inhalation Powder 62.5 microgram/1 Actuation to treat chronic obstructive pulmonary disease. 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 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 has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewers opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dupixent 300 milligrams/2 milliliter prefilled syringe, 26 syringes for 90 days prescribed for atopic dermatitis. The Part D plan denied your request because the drug is a specialty drug that is limited to a 30 day supply. 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 Dupixent to treat your atopic dermatitis. The prescriber statement indicates a request for Dupixent 300 milligrams/2 milliliter syringe for 26 syringes for a 90 day supply. The drug requested is a specialty drug and the plan states that specialty drugs are limited to a 30 day supply. The plan has approved a 30 day supply of the requested drug. Therefore, the plan is not required to cover Dupixent for 90 days.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipratropium/Albuterol 0.5-2.5milligrams/3milliliter nebulizer solution prescribed as directed for chronic obstructive pulmonary disease. 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Ipratropium/Albuterol nebulizer solution to treat your chronic obstructive pulmonary disease. However, we determined that the drug is not eligible for Part D coverage. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. 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 Ipratropium/Albuterol nebulizer solution because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit.You may wish to submit a request for Ipratropium/Albuterol nebulizer solution to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hyoscyamine sulfate .125 milligram tablet prescribed for unknown diagnosis. The Part D plan denied your request because Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. 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 the Hyoscyamine sulfate is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover Hyoscyamine sulfate. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Welchol 625 milligram tablet prescribed as directed for hyperlipidemia. 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. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The record shows that your doctor prescribed Welchol to treat your condition. The Medicare approved compendium supports the use of this drug to treat your condition. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Welchol because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine/Prilocaine 2.5% cream prescribed for anesthesia of skin. 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 the Lidocaine/Prilocaine 2.5% cream is prescribed for anesthesia of skin. The Medicare Part D Prescription Drug benefit does not cover drugs that are covered under the Medicare Part B End-Stage Renal Disease benefit. We determined that the plan is not required to cover Lidocaine/Prilocaine 2.5% cream. Medicare Part B is responsible for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trospium Chloride 20 milligram prescribed for to treat the enrollees condition. 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. There were no medical records submitted.The documentation is insufficient to determine what the enrollees diagnosis is or why the enrollee cannot take other drugs on the plans formulary. A physician reviewed your appeal and determined that the plan is not required to cover Trospium Chloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig solution auto-injector 70 milligrams/milliliters prescribed as directed to treat chronic migraines. 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. The documentation does not satisfy the plans 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 as the requested drug. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydroxyzine Pamoate 25 milligrams prescribed for migraine headaches. The Part D plan denied your request because the prescriber did not provide the detailed information necessary to cover this drug for a prior authorization. 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 Hydroxyzine Pamoate to treat your migraine headaches. 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 Pamoate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tadalafil 5 milligram tablets prescribed for erectile dysfunction. The Part D plan denied your request because drugs prescribed for sexual or erectile dysfunction do not meet the definition of Part D drugs. 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 determined that the plan is not required to cover Tadalafil because it was prescribed for sexual or erectile dysfunction. 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 Tadalafil 20 milligram tablets prescribed for the enrollees pulmonary hypertension. 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. The documentation supports the drug was prescribed for the enrollees diagnosis of pulmonary hypertension. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.