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

You requested Ketoconazole 200 milligram tablets prescribed as directed for hirsutism. 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 medical records showing the reason this drug was prescribed for you. However, we did not receive the documentation.We determined that the plan is not required to cover Ketoconazole because the documentation available for review shows it was prescribed for cosmetic purposes. Drugs prescribed for cosmetic purposes or hair growth 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 Lidocaine Anorectal 5% Cream prescribed four times daily for diabetic polyneuropathy. 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 determined that the plan is not required to cover Lidocaine Anorectal 5% Cream because it is an over the counter medication. Nonprescription or over-the-counter drugs are excluded from coverage. The enrollees plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, they must pay for them. 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 Shingrix vaccine prescribed for vaccination. 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 you received the vaccination at your physicians office. The plan submitted documentation that shows coverage was provided for the Shingrix vaccination. According to your plans Evidence of Coverage, your copay amount is $12. The plan calculates reimbursement 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 clinic charged you. We determined that the plan is not required to provide additional reimbursement for the Shingrix vaccine. The plan provided coverage and reimbursement in accordance with your plans out-of-network rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Timolol Maleate ophthalmic solution 0.5 percent prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Timolol Maleate ophthalmic solution is a generic drug on Tier 2 of the plans formulary. There are no generic 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 Hydroxyzine Hydrochloride 25 milligram tablets prescribed as directed for insomnia potentially secondary to anxiety. 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 Hydroxyzine Hydrochloride to treat your insomnia potentially secondary to anxiety. 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 Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil 20 milligram oral tablet prescribed daily for chronic thromboembolic pulmonary hypertension. 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 Sildenafil to treat your chronic thromboembolic pulmonary hypertension. 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 Sildenafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% Patch. At initial determination and redetermination the diagnoses of lower back pain and osteoarthritis of knees were given. The Part D plan denied the 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 coccyx pain was given. The use of the requested drug to treat the provided diagnoses are off-label uses. 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 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 Lyrica 100 milligram tablets prescribed three time daily for peripheral neuropathy, unspecified. 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 initially provided the diagnosis of peripheral neuropathy, unspecified.  In the request for reconsideration, the prescriber changed the diagnosis to severe diabetic neuropathy.  Recent medical records from date of service, April 20, 2021, were provided which do not document a diagnosis of diabetes.  The office notes provided do not support a diagnosis of severe diabetic neuropathy.  The use of the requested drug to treat peripheral neuropathy is not supported.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees 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 Lyrica.
Appeal type: Prescription Drug
Decision: Partially Favorable

At issue is Diphenoxylate Hydrochloride-Atropine Sulfate 2.5-0.025 milligram tablet prescribed as adjunctive therapy in the management of diarrhea. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The medical records show you prescribed Diphenoxylate Hydrochloride-Atropine Sulfate 2.5-0.025 milligram tablet as adjunctive therapy in the management of diarrhea. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The medical records submitted indicate that the medication at issue is being used as adjunctive add-on therapy in the management of diarrhea. The records also include a statement confirming that you are aware of the risks associated with this medication. The documentation provided does show the enrollee has satisfied the plan's coverage criteria. Therefore, the prior authorization criteria have been met. However, Diphenoxylate Hydrochloride-Atropine Sulfate 2.5-0.025 milligram tablet is a generic drug on Tier 3 of the plans formulary. The physician did not address why the drugs available on the lower tiers of your plans formulary would not work for the enrollee. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is required to cover Diphenoxylate Hydrochloride-Atropine Sulfate 2.5-0.025 milligram tablet. However, the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 0.5-milligram/2-milliliter. 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 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 also researched Medicare systems and reviewed the enrollment data available.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 Repatha Sureclick 140 milligram/milliliter auto-injector prescribed twice a month for hyperlipidemia. 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. 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 medical records do not support why the formulary drug Praluent would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix vial kit. 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. We also researched Medicare systems and reviewed the enrollment data available.The record shows you received the vaccination at a physicians office. The plan submitted documentation that shows coverage was provided for the Shingrix vaccination. The plans Evidence of Coverage indicates reimbursement is calculated 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 pharmacy charged you. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Risedronate Sodium 35-milligram tablet to treat osteoporosis. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 provided patient specific clinical rationale, supported by medical records, as to 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 formulary 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 Gralise 300 milligram tablets prescribed for restless leg 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 records 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 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 Gralise.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingles vaccine prescribed for vaccination. 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 plan indicates that a review of pharmacy claims shows the enrollee has already received two injections of the Shingrix vaccine, the first on December 6, 2020 and the second dose on March 22, 2021. The maximum dispensing limit for the Shingrix is two injections per lifetime. The record shows the enrollee was in the hospital during the time the second dose was administered. However, the hospital discharge summary that was provided only indicates medications for discharge. There is no evidence of what drugs were provided to the enrollee on date of service March 22, 2021, during the hospital stay. Therefore, we determined that the plan is not required to cover the Shingrix vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Hetlioz 20 milligram capsule prescribed for non-24-hour sleep-wake 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 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 did not receive a reply. The documentation shows your doctor prescribed Hetlioz to treat your non-24-hour sleep-wake disorder. 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 Hetlioz. 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 Esterified Estrogens-Methyltestosterone 0.625-1.25 milligram tablets prescribed as directed. 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 the physician prescribed Esterified Estrogens-Methyltestosterone. Esterified Estrogens-Methyltestosterone has not been approved by the Food and Drug Administration. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.We determined that the plan is not required to cover Esterified Estrogens-Methyltestosterone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ropinirole Hydrochloride extended release 2 milligram tablets prescribed as directed for restless leg 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. 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 medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Ropinirole Hydrochloride extended release.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for the ActHIB vaccine. 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 the vaccine. The National Drug Codes provided were verified with the Food and Drug Administration. The numbers were invalid and therefore, not eligible for coverage or under Medicare Part D.  We determined the plan is not required to cover and provide reimbursement for the ActHIB vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prior authorization for Cyclobenzaprine 10 milligram tablets prescribed as directed for chronic shoulder pain with muscle spasm. 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 Cyclobenzaprine to treat your chronic shoulder pain with muscle spasm. Your doctor also stated that you have a history of shoulder hemiarthroplasty.  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 Cyclobenzaprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azelastine 0.15% nasal spray prescribed to treat allergies.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the requested documentation.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 medical records do not support why other drugs on the plans formulary would not work for you.A physician reviewed your appeal and determined that the plan is not required to cover Azelastine 0.15% nasal spray.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zostavax vaccine prescribed for shingles vaccination. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The record shows you received the Zostavax vaccine at your physicians office. Payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or provider's office. You submitted documentation to the plan that includes a copy of an itemized bill. However, the record does not include proof of payment such as an itemized statement or receipt showing the bill was paid in full. We determined that the plan is not required to reimburse you for the vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Saxenda 18 milligram/3 milliliter pen injector for morbid 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 it was prescribed for weight loss. Drugs to treat anorexia, weight loss, or weight gain 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 Diclofenac Sodium 1% gel prescribed for chronic pain syndrome and patellofemoral 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 records show you prescribed Diclofenac Sodium 1% gel to treat the enrollees chronic pain syndrome and patellofemoral disorder. However, the 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 Diclofenac Sodium 1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diovan 160 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 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 did not receive the requested documentation.Your doctor prescribed Diovan 160 milligram tablets. No medical records have been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.A physician reviewed your appeal and determined that the plan is not required to cover Diovan 160 milligram tablets.