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

At issue is Lovaza 1 gram capsules. 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.Your prescriber indicates that you did not have a triglyceride level greater than or equal to 500 milligrams per deciliter prior to the start of treatment with this drug. Therefore, this medication is not medically indicated for your condition per Medicare approved compendia. A physician reviewed your appeal and determined that the plan is not required to cover Lovaza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus Solostar Pen Injector. 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. Lantus Solostar Pen Injector 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

At issue is Oxycontin Extended Release 30 milligram tablets prescribed for chronic 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. 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 all other drugs on the plans formulary would not work for you. There is no supporting evidence that all the plans formulary, alternative drugs, have been tried.A physician reviewed your appeal and determined that the plan is not required to cover Oxycontin Extended Release tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Novolin N 100 units per milliliter vial.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.On coverage determination, the Part D plan denied your request for a tiering exception. Novolin N 100 units per milliliter vial is not on your plans formulary. 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

At issue is a tiering exception request for Mesalamine DR 1.2 gram tablet to treat the enrollees condition.   The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Mesalamine DR 1.2 gram tablet is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  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 Colesevelam 625 milligram tablets prescribed for urge incontinence and diarrhea. 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 Colesevelam for urge incontinence and diarrhea. The Medicare approved compendia do not support the use of the drug at issue for your conditions. You submitted a statement to indicate your diagnosis should be mast cell colitis; however, this is not an accepted diagnosis. 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 Prolia 60 milligrams per milliliter syringe. 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.Prolia is a biological on Tier 4 of the plans formulary. There are no biologicals 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 Orencia 125 milligram/milliliter prescribed once weekly. 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 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

At issue is Procrit 10,000 units per milliliter prescribed for the enrollees condition. 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 asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.The documentation shows the doctor prescribed Procrit. There are no medical records to support a diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica 75 milligram capsules 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.This drug is not included on your plans formulary. 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 Cyclophosphamide 25 milligram capsule prescribed for natural killer T cell leukemia and hemolytic anemia. 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 Cyclophosphamide 25 milligram to treat the enrollees natural killer T cell leukemia and hemolytic anemia. However, the Medicare approved compendia and Medicare approved journals do not support the use of this drug for this condition. An oncologist reviewed your appeal and determined that the plan is not required to cover Cyclophosphamide 25 milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ure-Na 15 gram/100 milliliter packets prescribed for hyponatremia. 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 Ure-NA because it is an over-the-counter drug. Nonprescription or over-the-counter drugs 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 Qutenza Patch 8% prescribed for diabetic neuropathy. 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. 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 all other drugs, for your condition, on the plans formulary would not work for you. There is no supporting evidence that all the plans formulary, alternative drugs, have been tried.A physician reviewed your appeal and determined that the plan is not required to cover Qutenza Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Epolamine 1.3% transdermal patch for chronic pain syndrome and chronic 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 1.3% transdermal patch for chronic pain syndrome and chronic back pain. 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 Diclofenac Epolamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500 milligram tablet prescribed two times per day for pemphigus vulgaris. 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. The documentation shows the doctor prescribed Mycophenolate Mofetil for the enrollees pemphigus vulgaris. 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Cypionate 200 milligram/milliliter intramuscular injection was prescribed for testicular hypofunction. 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 levelWe 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 documentation requested.The documentation shows your doctor prescribed Testosterone Cypionate 200 milligram/milliliter intramuscular injection for testicular hypofunction. 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 cover Testosterone Cypionate. 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 a compound cream consisting of Ketamine, Gabapentin, Baclofen, Flexeril, Diclofenac, and Bupivacaine prescribed for 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.For a compound item to be approved, all ingredients that are Part D drugs must be shown as being used for a medically accepted indication and route of drug must be supported by Medicare approved compendia. Gabapentin only has a medically accepted indication for an oral route or administration. Therefore, the compound is not eligible for Part D coverage. A physician reviewed your appeal and determined that the plan is not required to cover Ketamine, Gabapentin, Baclofen, Flexeril, Diclofenac, and Bupivacaine compound cream.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate 2.5 milligram/3 milliliter prescribed for asthma. The Part D plan denied the request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The record shows Albuterol Sulfate is being administered through a nebulizer in the home setting. 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 Albuterol sulfate. Please submit your request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Dronabinol 2.5 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 Dronabinol has been prescribed for appetite stimulation due to the presence of esophageal dysplasia and severe protein calorie malnutrition. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for a tiering exception for Entresto 49-51 milligram tablets prescribed for congestive heart failure with hypertension. 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.Entresto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Entresto at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for a tiering exception for Eliquis 5 milligram tablets prescribed for paroxysmal atrial fibrillation. 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. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Eliquis at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is NP Thyroid 30 milligram tablets prescribed to treat hypothyroidism. 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. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage.  Per the Medicare approved compendia, the drug has not been found by the United States Food and Drug Administration to be safe and effective, and the drug product labeling has not been approved by the Food and Drug Administration. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to cover NP Thyroid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram capsule (90 capsules every 30 days) for pain. 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 documentation shows your doctor prescribed Dronabinol to treat your pain. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Northera 200 milligram capsules prescribed for orthostatic hypotension. 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.Your medical records show your doctor prescribed Northera to treat your orthostatic hypotension. 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 cover Northera. 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 Ozempic 1 milligram/0.75 milliliter pen prescribed for type II diabetes mellitus. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.Ozempic 1 milligram/0.75 milliliters pen 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 for Lidocaine 5% Patch prescribed for chronic pain. The Part D plan denied your request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The documentation shows your doctor prescribed Lidocaine 5% Patch to treat your diabetic neuropathy. 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 5% Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide, 1 milligram in 2 milliliter vials, prescribed for the treatment of 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 documentation indicates that the Budesonide is being administered to the enrollee via a nebulizer in a skilled nursing facility. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment, such as a nebulizer. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Coverage under Part D is excluded for any drug for which payment would be available under Part B. We determined that the Medicare Part D plan is not required to cover the Budesonide. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.