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

At issue is Xeljanz Extended Release 11-milligram tablet to treat rheumatoid arthritis. 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 5 milligram tablets prescribed for left-sided back pain. 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.The submitted documentation indicates the prescriber ordered Cyclobenzaprine Hydrochloride for left-sided back pain. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for autologous serum eye drops purchased on December 15, 2020, which have been prescribed for the treatment of keratitis sicca. 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.Autologous serum eye drops have not been approved by the Food and Drug Administration (FDA). Because the drops are a unique blood product, they cant be mass-produced for FDA approval. Drugs not approved by the FDA are excluded from Part D coverage. We have determined that the Medicare Part D plan is not required reimburse payment for the requested drug. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Lorazepam prescribed for an unknown diagnosis. 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 plan reprocessed the enrollees claim for the Lorazepam and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because Medicare records indicate the enrollee did not qualify for low income subsidy copay level. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the remaining copay. We have determined that the plan is correct in its recalculation of the enrollees copay.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Metformin Hydrochloride prescribed for an unknown diagnosis. 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 plan reprocessed the enrollees claim for the Metformin Hydrochloride and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because Medicare records indicate the enrollee did not qualify for low income subsidy copay level. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the remaining copay. We have determined that the plan is correct in its recalculation of the enrollees copay.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Methylprednisolone dose pack prescribed for an unknown diagnosis. 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 plan reprocessed the enrollees claim for the Methylprednisolone and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because Medicare records indicate the enrollee did not qualify for low income subsidy copay level. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the remaining copay. We have determined that the plan is correct in its recalculation of the enrollees copay.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Minocycline Hydrochloride prescribed for an unknown diagnosis. 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 plan reprocessed the enrollees claim for the Minocycline Hydrochloride and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because Medicare records indicate the enrollee did not qualify for low income subsidy copay level. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the remaining copay. We have determined that the plan is correct in its recalculation of the enrollees copay.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Sulfamethoxazole Trimethoprim DS prescribed for an unknown diagnosis. 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 plan reprocessed the enrollees claim for the Sulfamethoxazole Trimethoprim and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because Medicare records indicate the enrollee did not qualify for low income subsidy copay level. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the remaining copay. We have determined that the plan is correct in its recalculation of the enrollees copay.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Tramadol HCL prescribed for an unknown diagnosis. 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 plan reprocessed the enrollees claim for the Tramadol HCL and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because Medicare records indicate the enrollee did not qualify for low income subsidy copay level. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the remaining copay. We have determined that the plan is correct in its recalculation of the enrollees copay.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Trazodone Hydrochloride prescribed for an unknown diagnosis. 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 plan reprocessed the enrollees claim for the Trazodone Hydrochloride and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because Medicare records indicate the enrollee did not qualify for low income subsidy copay level. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the remaining copay. We have determined that the plan is correct in its recalculation of the enrollees copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Prolastin-C 1000 milligram/20 milliliter injection solution prescribed for alpha-1 antitrypsin deficiency. The Part D plan denied coverage.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 records submitted at the reconsideration level. The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested Prolastin-C is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Repatha Sureclick 140 milligram/milliliter pen injector prescribed for hyperlipidemia with atherosclerotic cardiovascular disease. The Part D plan denied coverage.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 records submitted at the reconsideration level. The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested Repatha Sureclick is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Savaysa 60 milligram tablets prescribed for 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.In 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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Savaysa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request fort for Enemeez Mini Enema 283 milligram/5 milliliter. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. Drugs prescribed that are available over the counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.We determined that the plan is not required to cover Enemeez Mini Enema.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a prior authorization request for Entresto 24-26 milligram tablets prescribed for chronic heart failure. The Part D plan denied coverage.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 records submitted at the reconsideration level. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee meets the plans prior authorization coverage criteria. We received the requested information and included in the review.The records received support the prescriber ordered Entresto to treat chronic heart failure, New York Heart Association Class III. The enrollee will not be using the drug with or within 36 hours of an Angiotensin-converting enzyme inhibitor. The enrollee does not have diabetes and will not be using Entresto in combination with Aliskiren. The enrollee satisfies the plans prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temozolomide 140 milligram capsules prescribed for glioma of spinal cord. 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.The record shows the prescriber ordered Temozolomide to treat glioma of spinal cord. However, the drug at issue is an oral cancer drug that has the same active ingredient as an injectable drug. Oral cancer drugs that contain the same active ingredient as injectable dosage forms are covered under Medicare Part B. The drug at issue is not considered a Part D benefit.We determined that the plan is not required to cover the Temozolomide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Typhim VI 25 microgram/0.5 milliliter injection prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.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.Typhim VI is a biologic on Tier 3 of the plans formulary. There are no biologics of the same type on the lower cost sharing tiers. Therefore, this biologic is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gamunex C 10-milligrams/milliliter to treat refractory myasthenia gravis. 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.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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Olanzapine/Fluoxetine Hydrochloride 3 milligram/25 milligram capsules prescribed for anxiety and hallucinations in an enrollee with mild intellectual disabilities. 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.The submitted documentation indicates the prescriber ordered Olanzapine/Fluoxetine Hydrochloride for anxiety and hallucinations in an enrollee with mild intellectual disabilities. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Testosterone Cypionate 200 milligram/milliliter solution prescribed for primary hypogonadism. The Part D plan denied coverage.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 documentation on hand includes medical records and a supporting statement. The documentation does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.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 a request for coverage of Fentanyl 75 microgram/hour transdermal patch prescribed every 3 days for cervical disc disease and 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 levelThe documentation shows your doctor prescribed Fentanyl to treat cervical disc disease and chronic pain. However, your medical records do not support why an exception to the plans quantity limit is medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover the Fentanyl as the drug exceeds the accumulated morphine equivalent dose that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Epclusa 400-100-milligram tablet. At initial determination and redetermination the diagnosis of acute hepatitis C without hepatic coma was 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 the diagnosis of chronic hepatitis C with cirrhosis of transplanted liver was given. The documentation satisfies the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Bystolic prescribed for an unknown diagnosis. 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 plan reprocessed a claim for the Bystolic and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for your share of any deductible and copay that was not applied at the point of sale. We have determined that the plan is correct in its calculation of additional copay amounts due to reconciliation of your true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Olopatadine HCL prescribed for an unknown diagnosis. 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 plan reprocessed a claim for the Olopatadine HCL and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for your share of any deductible and copay that was not applied at the point of sale. We have determined that the plan is correct in its calculation of additional copay amounts due to reconciliation of your true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed for muscle spasms associated with myotonic dystrophy, type I. 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.The submitted documentation indicates the prescriber ordered Cyclobenzaprine Hydrochloride for muscle spasms associated with myotonic dystrophy, type I. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pennsaid 2% solution prescribed for lumbar radiculitis, lumbar stenosis, chronic bilateral low back pain with right side sciatica, and spondylosis of lumbosacral region without myelopathy or radiculopathy. 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 prescriber indicates that Pennsaid 2% solution is prescribed for lumbar radiculitis, lumbar stenosis, chronic bilateral low back pain with right side sciatica, and spondylosis of lumbosacral region without myelopathy or radiculopathy. 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 Pennsaid 2% solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Patch 5% prescribed for chronic lumbar pain. 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 prescriber indicates that Lidocaine Patch 5% is prescribed for chronic lumbar pain. 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 Lidocaine Patch 5%.