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

You requested Uribel 118 milligram capsules prescribed as directed for dysuria. 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 Uribel for dysuria. Uribel 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 Uribel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Hyqvia 20 gram-1600 unit pack for subcutaneous injection prescribed for hypogammaglobulinemia. 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 your case file carefully. We reviewed all documentation submitted. Hyqvia is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternative(s) included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. 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

You requested Buprenorphine Hydrochloride 2 milligram sublingual tablets prescribed as directed for chronic 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 the doctor prescribed Buprenorphine Hydrochloride sublingual tablets to treat chronic low back pain. However, the Medicare approved compendia do not support the use of this drug in sublingual tablet form for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Epolamine 1.3% topical patches prescribed as directed for chronic lower 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 the doctor prescribed Diclofenac Epolamine to treat chronic lower back pain. However, the Medicare approved compendia do not support the use of this drug for the enrollees chronic condition. A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Epolamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus 100 units per milliliter solution. 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 asked your prescriber to send us information regarding 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 other medications on the plan's formulary would not work for you. However, we did not receive the documentation.At initial determination the diagnosis of illness, unspecified was given. However, the Medicare approved compendia do not support the use of this drug for your condition. No medical records have been submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication. The formulary exception was not addressed because 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 Lantus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 micrograms/actuation inhaler prescribed as directed for chronic obstructive pulmonary 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 records submitted at the reconsideration level.The medical records show the doctor prescribed Anoro Ellipta to treat chronic obstructive pulmonary disease. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria. It is noted the prescriber also requested a tiering exception for this drug at reconsideration. However, a tiering exception cannot be considered at this time because the drug has not been approved for coverage by the plan.A physician reviewed your appeal and determined that the plan is not required to cover Anoro Ellipta. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 20.25 milligrams/actuation (1.62%) gel prescribed as directed for low testosterone levels. 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 the doctor prescribed Testosterone to treat low testosterone levels. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Testosterone. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligram tablets to treat erectile dysfunction and pulmonary hypertension. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Repatha Sureclick 140 milligram/milliliter injection. 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 does not contain a supporting statement or medical records to support a prescribed diagnosis. A request for information was sent to the prescriber.  However, no further documentation was received. As it cannot be determined that the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sure Click 140 milligram/milliliter solution auto injector prescribed as directed for atherosclerotic heart disease of native coronary artery without angina pectoris, and hyperlipidemia, 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. This medication is not on your plan's list of medications. The prescriber has not given a clear medical reason why medications on that list did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. 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 Repatha Sure Click.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Alphagan P 0.15% eye drops prescribed for glaucoma from ocular inflammation. 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 Alphagan P for glaucoma from ocular inflammation. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As the drug was not 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 Sodium Bicarbonate 8.4% solution for intravesicular administration prescribed as directed for interstitial cystitis. 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 the doctor prescribed Sodium Bicarbonate to treat interstitial cystitis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Sodium Bicarbonate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gamunex-C 20 grams per 200 milliliter solution prescribed every 28 days for inclusion body myositis. 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 shows the doctor prescribed Gamunex-C to treat the enrollees inclusion body myositis. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Gamunex-C.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac 50 milligram 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. You are requesting reimbursement for Diclofenac suppository given to you while in the hospital. We researched Medicare resources and found that drug Diclofenac suppository has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover or reimburse you for the Diclofenac suppository. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate nebulizer solution prescribed for chronic obstructive pulmonary disease. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows Albuterol Sulfate was prescribed for chronic obstructive pulmonary disease. However, this drug may be eligible for coverage under Medicare Part B. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Albuterol Sulfate. 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.We determined that the plan is not required to cover Albuterol Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armodafinil 50 milligram tablet prescribed daily for fatigue related to multiple sclerosis. 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 shows the doctor prescribed Armodafinil to treat the enrollees fatigue related to multiple sclerosis. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Febuxostat 40 milligram tablets prescribed for chronic gout. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Febuxostat has been 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 the appeal and determined that the plan is not required to grant a lower-cost tiering exception for the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Shingrix 50 microgram per 0.5 milliliter vaccine prescribed for prophylaxis. The Part D Plan did not allow the request.We performed an independent and de novo review. We reviewed all documentation submitted. The record shows the enrollee is over 50 years of age and received the Shingrix vaccine. Proof of payment was submitted.We determined that the plan is required to reimburse you for the Shingrix vaccine.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Boostrix 18.5 micrograms/0.5 milliliters-2.5 Lf-units/0.5 milliliters-5 Lf-units/0.5 milliliters vaccine prescribed for pertussis-diptheria-tetanus vaccination. The Part D Plan did not allow the request.We performed an independent and de novo review. We reviewed all documentation submitted. The record shows the enrollee is over 10 years of age and received the Boostrix vaccine. Proof of payment was submitted.We determined that the plan is required to reimburse you for the Boostrix vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pneumovax 23 injectable 25 microgram/0.5 for vaccination.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 Pneumovax vaccination from your pharmacy. The Pneumovax vaccine is excluded from coverage under Medicare Part D. Medicare rules state that a drug covered under Part B cannot be covered under Part D. Therefore, the Part D plan is not required to cover or provide reimbursement for the Pneumovax vaccine. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Otezla 30 milligram oral tablet prescribed for lichenoid dermatitis. 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 Otezla to treat your lichenoid dermatitis. 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 Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Colchicine 0.6 milligram capsules prescribed daily for other chondrocalcinosis, unspecified site. 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 Colchicine to treat your chondrocalcinosis, unspecified site. 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 Colchicine.
Appeal type: Prescription Drug
Decision: Unfavorable

Carbidopa-Levodopa-Entacapone 25-100-200 milligram tablets was prescribed for an unspecified condition.  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.A request was submitted to the prescriber to provide a diagnosis, to address the tiering exception 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 Baclofen 10 milligram tablet prescribed for you while inpatient in the hospital emergency room. 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 hospital submitted Baclofen with National Drug Code 00832-1024-00 for payment to your plan. We found that National Drug Code 00832-1024-00 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Baclofen. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested GNP Lidocaine 4% pad prescribed while you were inpatient in the hospital emergency room. 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. According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. We determined that the plan is not required to cover the GNP Lidocaine pad or provide reimbursement. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Naproxen 250 milligram tablet prescribed for you while inpatient in the hospital emergency room. 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 hospital submitted Naproxen with National Drug Code 00093-0147-01 for payment to your plan. We found that National Drug Code 00093-0147-01 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Naproxen. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix 50 micrograms injection prescribed for shingles 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 were administered the Shingrix vaccine at your physicians office. Payment for vaccines including administration fee is required up front when provided at an out of network pharmacy or provider's office. You will be reimbursed the amount you paid less any deductible, copayment or coinsurance and less the amount the physician charges and the plans approved amount. The plans Evidence of Coverage states that you have a deductible of $195 for the tier 3 drug Shingrix. The plan submitted documentation that shows you were still in the deductible stage when you received the Shingrix vaccination. Therefore, the plan processed the claim and applied the allowable amount for the Shingrix to your deductible. We determined that the plan is not required to further reimburse you for the vaccine.