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

At issue is Basaglar Kwikpen 100 units/milliliters prescribed as directed for an unknown diagnosis. 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 records submitted at the reconsideration level. The prescriber was asked to state the diagnosis since the diagnosis was not contained within the appeal. The prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the plans lower tier alternatives. We did not receive a response from the prescriber.Therefore, based upon the current record, 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 reimbursement under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Abilify 5 milligram tablets, 90 tablets per 90 days, prescribed for depression. 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. Abilify is not included in the plans formulary. Although a non-formulary approval has been granted for the Abilify, the plan does not grant tiering exceptions to non-formulary drugs. Therefore, the Abilify is not eligible for coverage at a lower-cost tier. Additionally, the plan has approved the Abilify at a recurring 30-day supply, and a 90-day supply of the medication will not be approved.  A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception. Furthermore, the plan will only cover a recurring 30-day supply of the medication.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tudorza Pressair 400 microgram inhaler, three inhalers every 30 days to treat an unknown diagnosis. The Part D plan denied the request for the excess inhalers. 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 plan limits the amount of Tudorza Pressair to one inhaler every 30 days. The physician attestation supports the request was for one inhaler every 30 days. The requested quantity is within the plans allowed quantity limit. Our physician reviewer's opinion is that quantity limit criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armour Thyroid 90 milligram tablets prescribed daily to treat hypothyroidism, unspecified. The Part D plan denied your request.We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Non- Food and Drug Administration (FDA) approved drugs are excluded from Medicare Part D coverage. Per the Medicare approved compendia, This drug has not been found by the US FDA to be safe and effective, and the drug product labeling has not been approved by the FDA. Therefore, the requested drug is excluded from coverage. A physician reviewed your appeal and  determined that the plan is not required to cover the Armour Thyroid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuplazid 34-milligram capsules to treat dementia with Lewy bodies. 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 use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 Levalbuterol Tartrate 45 micrograms prescribed as directed for scleroderma, sclerotic lung disease, and fibrotic lung disease. 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 also researched Medicare systems and reviewed the enrollment data available. The use of the requested drug to treat the provided diagnoses is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Levalbuterol Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tolak 4% cream prescribed for actinic keratosis. 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 NDC (National Drug Code Directory) number that was received by the plan for authorization 64370-0421-40 references a formulation of the drug Tolak that is no longer FDA approved as of December 31, 2020. Therefore it is not considered a Part D drug, is excluded, and the plan is not required to provide coverage
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 50 milligram tablet. 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. At initial determination and redetermination the diagnosis of interstitial pulmonary disease, unspecified was given. At reconsideration a diagnosis of Raynauds disease was given.  Medical records to support Raynauds were not submitted. The documentation does not support the requested drug was being prescribed for a medically accepted indication approved by the Food and Drug Administration. 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 Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyanocobalamin to treat Vitamin B12 deficiency secondary to Crohns disease. The Part D plan denied the request. 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.Drugs prescribed for use as vitamins and minerals are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsule prescribed for your non 24-hour sleep-wake disorder. 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 your condition. However, you do not satisfy the plan's prior authorization coverage criteria. There were no medical records to support you are totally blind as required by the plan for coverage.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Cyclobenzaprine Hydrochloride 10 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.You stated that the Cyclobenzaprine Hydrochloride was prescribed for your back problems. However, back problems is not a specific enough diagnosis to determine if the medication is being prescribed for a medically accepted indication.  A request was submitted to the doctor who prescribed the medication to provide a diagnosis, for clarification, and to provide supporting medical records. We did not receive any medical records from the prescribing physician.Without a specific 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 coverage for Tacrolimus 0.03% ointment prescribed for an unknown condition. The Part D plan forwarded your request to us for review. 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 Part D plan has prior authorization requirements that must be met before coverage for Tacrolimus ointment is approved. A request was submitted to your doctor to provide a diagnosis, to address the plans coverage 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 cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Temazepam 30 milligram capsules prescribed for insomnia. 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. The submitted documentation indicates your doctor prescribed Temazepam for long-term treatment of insomnia. 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

You requested Promethazine HCL 12.5 milligram suppositories prescribed as directed for drug induced constipation and gastroparesis. 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 also researched Medicare systems and reviewed the enrollment data available. The use of the requested drug to treat the provided diagnoses is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and  determined that the plan is not required to cover the Promethazine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Methylphenidate Hydrochloride ER 20 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 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 from you doctor indicates that Methlyphenidate Hydrochloride ER has been prescribed for the management of your major depressive disorder. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the noted condition. The detailed letter from the prescriber is acknowledged. 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 Methlyphenidate Hydrochloride ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Invokana 300 milligram oral tablets prescribed daily for type II diabetes. The Part D plan auto-forwarded the case. 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. Invokana is a brand drug that is not on the plans formulary. Medicare has already granted a formulary exception for the drug. A tiering exception cannot be allowed for a drug that is not on the plans formulary. 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 a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Crestor 40 milligram tablets prescribed 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.Crestor is a non-formulary brand drug. 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 Humira pen 40 milligram/.8 milliliter injection prescribed for Crohns disease. The Part D plan denied your request.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 record shows you received the Humira pen injection in the hospital. 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 pharmacy 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, proof of payment in the form of a receipt showing the amount that you paid was not provided. Therefore, we determined that the plan is not required to reimburse you without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bystolic 5 milligram oral tablet. The Part D plan denied your request. We received an auto-forwarded reconsideration request from the coverage level. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. Bystolic 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: Unfavorable

At issue is Humira 40 milligrams/0.8 milliliter pen injection kit to treat pyoderma gangrenosum. 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 use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  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

At issue is Sumatriptan 6 milligrams per 0.5 milliliter cartridges prescribed for subcutaneous injection to treat the enrollees condition. The Part D plan denied your request for a tiering exception.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.Sumatriptan 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. 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 compounded drug Diazepam 5 milligram powder, baclofen 20 milligram powder, Lidocaine 40 milligram powder, gabapentin 2 milligram powder suppository 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 plan denied your request for reimbursement because valid National Drug Codes were not provided for some of the ingredients of the compounded drug. The National Drug Codes provided were verified with the Food and Drug Administration. The numbers were invalid and therefore, not eligible for coverage under Medicare Part D.  We determined the plan is not required to provide reimbursement for the compounded drug Diazepam/baclofen/lidocaine/gabapentin suppository.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis Multidose 0.05% eye drops prescribed for your dry eyes. 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. Restasis 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 a tiering exception for Livalo 4-milligram tablets prescribed for hyperlipidemia. The Part D plan denied your request for a tiering exception because Livalo is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative 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 plan shows Livalo is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Saxenda 18 milligrams/3 milliliters injection pen prescribed for obesity. 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. We determined that the plan is not required to cover Saxenda because drugs used for weight loss 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

You requested Myrbetriq ER 25 milligram tablets prescribed daily for overactive bladder. 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 also researched Medicare systems and reviewed the enrollment data available. 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 of the plans formulary. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.