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

At issue is Zolpidem Tartrate 5 milligram tablets 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 records 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 received the documentation and included it in our review.Your medical records show your doctor prescribed Zolpidem Tartrate 5 milligram tablets to treat your insomnia. 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 you have satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Zolpidem Tartrate 5 milligram tablets. 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

You requested Cresemba 186 milligram capsules prescribed daily for coccidioidal meningitis. 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 indicates your doctor prescribed Cresemba 186 milligram capsules prescribed daily for coccidioidal meningitis. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Patch 5 % prescribed to treat lumbar pain. 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.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. There were no medical records submitted. The prescriber submitted answers to questions that we sent but did not address all questions as required. There were no medical records submitted to support the diagnosis.In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, medical records are required. These records were requested from the prescriber, and we did not receive information that could answer these medical necessity issues.  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 Lidocaine Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for complete rotator cuff tear. 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 Lidocaine 5% patch to treat your complete rotator cuff tear. 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Actemra Actpen 162 milligram/0.9 milliliter solution auto injector prescribed for temporal arteritis. 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 prescriber statement shows Actemra Acten was ordered for temporal arteritis.  Actemra Acten is the only FDA approved biologic for the treatment of this condition.  Additionally, the prescriber has indicated why alternatives such as prednisone would likely not be as effective as the requested drug for you, or would likely cause adverse reaction(s). Therefore, an exception to the Plans formulary is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 60 milligram tablet prescribed for bipolar disorder. The Part D plan denied your request for a tiering exception.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data availableThis drug is included on Tier 5 of the plans formulary. This Tier is identified as a Specialty Tier. The plan is not required to grant a tier exception for drugs available on their Specialty Tier. Therefore, a tier exception cannot be considered.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 Mycophenolate Sodium 360 milligram tablets prescribed two tablets twice daily for autoimmune hepatitis. 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 indicates your doctor prescribed Mycophenolate Sodium for autoimmune hepatitis. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cevimeline Hydrochloride 30 milligram capsules. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Cevimeline Hydrochloride has been prescribed for xerostomia due to cancer treatment. 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 your appeal and determined that the plan is not required to cover Cevimeline Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sivextro 30 milligram capsules. The Part D plan denied the request for coverage because the plans prior authorization requirements were not met.  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 Sivextro has been prescribed for a local bacterial infection of the skin and subcutaneous tissue caused by mycobacterium chelonae. 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 your appeal and determined that the plan is not required to cover the Sivextro.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Stelara 130 milligram/26 milliliter vial prescribed for moderately active ulcerative colitis. This case was an autoforwarded coverage determination.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 that Stelara is prescribed to treat moderately active ulcerative colitis and prior alternatives have been tried. The Plan has approved the subcutaneous maintenance version of this drug for the plan year. The requested formulation is for intravenous delivery as an induction therapy. It was approved under the Medicare part B coverage insurance. The request is for Part D coverage of this drug. This formulation is not on the plans formulary.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary 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 formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.A physician reviewed your appeal and determined that the plan is not required to cover Stelara 130 milligram/26 milliliter vial.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tretinoin 0.1 percent cream prescribed for cystic acne vulgaris..   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.  In the Reconsideration appeal the prescriber submitted a supporting statement and clarification of the diagnosis.The documentation satisfies the plans coverage criteria.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Morphine Sulfate ER 30 milligram tablets prescribed two tablets twice daily for chronic pain syndrome. 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 for medical records or other documentation to show why you need this amount of the medication. We did not receive the documentation requested.The medical records show you prescribed two tablets of Morphine Sulfate ER 30 milligram twice daily to treat the enrollees chronic pain syndrome. The plan has approved the prior authorization and safety edit. However, your medical records do not support why an exception to the plans quantity limit is medically necessary. It is noted that a 60-milligram tablet of the same medication is available on the plans formulary.A physician reviewed your appeal and determined that the plan is not required to cover the Morphine Sulfate ER 30 milligram tablets, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 150 milligram tablets prescribed daily for unspecified fatigue related to multiple sclerosis. 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 indicates your doctor originally prescribed Armodafinil for fatigue related to multiple sclerosis. The Medicare approved compendia do not support the use of this drug for your condition. Your doctor submitted a statement to indicate you also have excessive daytime sleepiness associated with obstructive sleep apnea; however, there were no medical records submitted to support the drug at issue was prescribed for this condition. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rosuvastatin Calcium 10 milligram tablets prescribed daily for the enrollees condition. 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.Rosuvastatin Calcium is a generic drug on Tier 2 of the plans formulary. A supporting statement and medical records were requested from your doctor; however, no further documentation was received. The documentation on hand does not address why all alternative lower-tier medication on the plans formulary would not work for you. 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 Lidocaine 5% patch prescribed for hip and knee pain from osteoarthritis. 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 a Lidocaine patch for hip and knee pain from osteoarthritis. However, the Medicare approved compendia do not support the use of this drug for your condition.  In the Reconsideration appeal medical records were requested and were not provided.  A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 4 milligram tablets prescribed for hyperlipidemia. 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. We asked your prescriber to send us information about your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why similar medications on the lower tiers would not work for you. . We received some of the documentation requested and included it in our review.Livalo is a brand drug on Tier 4 of the plans formulary. Your doctor did not address why all the drugs available on the lower tiers of your plans formulary would not work for you. 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 Temazepam 30 milligram capsule prescribed daily, a quantity of 30 capsules per 30 day supply for generalized anxiety 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need this amount of the medication. We received the other documentation and included it in our review. Use of Temazepam for treatment of anxiety associated with generalized anxiety disorder is an off label usage supported by a positive citation in the Medicare approved compendia, Micromedex. In the comparative efficacy section, All drugs were equally efficacious in relieving anxiety and depression in a study involving 51 psychiatric outpatients comparing lorazepam 2 milligrams with temazepam 20 milligrams and placebo. In this study, Temazepam is used on a daily basis for treatment of anxiety. The quantity limits imposed by the Plan reference use for insomnia. The prescriber has indicated that the number of doses of the requested drug allowed by the plan has not been effective in treating the condition.  Therefore, an exception to the plans quantity limit coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix 50 microgram/0.5 milliliter vaccine kit prescribed for shingles vaccination. The Part D plan was unable to review your case timely and auto-forwarded 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 record shows you received the Shringrix vaccination at your physicians office. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network physicians office charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, you did not provide proof of payment for the vaccine and its administration in the form of a receipt. Therefore, we determined that the plan is not required to reimburse you. Please submit proof of payment to your plan for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 50 milligram tablets prescribed for migraine. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 3% gel to treat arm and low back pain. 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 Diclofenac Sodium 3% gel to treat arm and low back pain. However, the use of the requested drug to treat the provided diagnosis is an off-label use. 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 Diclofenac Sodium 3% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Isosource 1.5 cal liquid. 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 reviewed your appeal carefully. We reviewed all documentation available. Drugs prescribed that are available over the counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.We determined that the plan is not required to cover Isosource.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone alcohol gel 100 milligram/milliliter 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. The record shows Testosterone alcohol gel is a compounded drug consisting of testosterone powder, glycerin liquid, alcohol solution, krisgel gel, and sterile water irrigation solution. Medicare Part D does not cover non-prescription drugs. All of the ingredients within the compounded drug except Testosterone are over-the-counter drugs and are not eligible for Part D coverage. We also found that the National Drug Code submitted for the active ingredient Testosterone powder is not listed with the Food and Drug Administration as a valid code. Therefore, we determined the plan is not required to reimburse you for the compounded drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix 50 microgram/0.5 milliliter vaccine prescribed for shingles vaccination. The Part D plan was unable to review your case timely and auto-forwarded 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 record shows you received the Shringrix vaccination at your physicians office. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network physicians office charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, you did not provide proof of payment for the vaccine and its administration in the form of a receipt. Therefore, we determined that the plan is not required to reimburse you. Please submit proof of payment to your plan for reimbursement.