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

You requested Marinol 5 milligram capsules prescribed as directed for autism, bipolar disorder, mental retardation, disruptive behavior disorder, and Tourette's like outburst. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows the doctor prescribed Marinol to treat autism, bipolar disorder, mental retardation, disruptive behavior disorder, and Tourette's like outburst. 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 Marinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hyoscyamine 0.125 milligram tablet prescribed as directed for irritable bowel syndrome. We received an auto-forward 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.Non-FDA approved drugs are excluded from Medicare Part D coverage.  Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dok 100 milligram capsules prescribed while you were in the hospital. 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 Dok or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Phenazopyridine Hydrochloride 200 milligram tablet to treat the enrollees condition during a Part A inpatient stay. The case was auto-forwarded by the plan.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 Medicare Part D drug plan cannot cover drugs classified as being part of the Food and Drug Administration (FDA)'s Drug Efficacy Study Implementation (DESI) program. These drugs are considered to be Less than Effective (LTE) per FDA review. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Tylenol 325 milligram. 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. Drugs prescribed that are available Over the Counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Polyethylene glycol 3350 17 gram powder pack prescribed while you were in the hospital. 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 Polyethylene glycol or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sodium citrate-citric acid 334-500 milligram solution prescribed while you were in the hospital. 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 Sodium citrate or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cetirizine Hydrochloride 10 milligram tablets. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. The record shows you were billed for Cetirizine Hydrochloride during your hospital stay and are requesting reimbursement for $20.00. We determined that the plan is not required to reimburse you for Cetirizine Hydrochloride. Drugs considered as nonprescription or-over- the-counter drugs are excluded from coverage under Medicare Part D. Therefore, the requested Cetirizine Hydrochloride is excluded from coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Montelukast sodium 10 milligram tablets prescribed for unknown diagnosis. The Part D plan approved coverage for the drug.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.The record shows you received Montelukast sodium while you were in the hospital. You submitted documentation to the plan that includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by you. The documentation provided indicates the plan approved payment for the Montelukast sodium. Therefore, we determined that the plan is required to reimburse you. The plan calculates reimbursement based on the total cost of the drug, minus any deductible, and your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the out-of-network pharmacy (i.e., hospital) charged you.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eylea 2 milligram/0.05 milliliter intravitreal injection prescribed once a month for exudative age-related macular degeneration, left eye, with active choroidal neovascularization. The plan did not make a decision within the required timeframe. The case was auto-forwarded by the plan.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 record shows the physician prescribed Eylea to treat exudative age-related macular degeneration, left eye, with active choroidal neovascularization. This injectable drug is administered intravitreally (inside the eye) by the physician. However, this drug is eligible for coverage under Medicare Part B. Drugs provided incident to a physician service are eligible for coverage under Medicare Part B, and excluded from coverage under Medicare Part D. We determined that the plan is not required to cover Eylea.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone 1.62 percent gel pump prescribed as directed for late onset hypogonadism, testicular hypofunction, erectile dysfunction, and benign prostatic hyperplasia without lower urinary tract symptoms. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Testosterone 1.62 percent gel to treat your late onset hypogonadism, testicular hypofunction, erectile dysfunction, and benign prostatic hyperplasia without lower urinary tract symptoms. However, the Medicare approved compendia do not support the use of this drug for your condition. The following citation was referenced in DrugDex, a Medicare approved compendia: 'The safety and efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism.' Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Testosterone 1.62 percent gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cimzia 200 milligram vial prescribed for 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. The documentation provided shows Cimzia was supplied by you and administered to the enrollee in your office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover Cimzia. 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: Favorable

At issue is Xifaxan 550 milligram tablets prescribed for irritable bowel syndrome with diarrhea. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records from date of service 3/19/2021 to support the enrollee was prescribed Xifaxan for irritable bowel syndrome with diarrhea. The enrollee has not previously been on the medication.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Vraylar 1.5 milligram capsule to treat the enrollees condition. The Part D plan denied the request. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Welchol 625 milligram tablets prescribed to treat irritable bowel 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. 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 Welchol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Gralise Extended Release 600 milligram 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.This drug is being 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested the Shingrix vaccine. The Part D plan denied coverage. 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 submitted.Without a diagnosis or medical documentation, it cannot be established that the requested vaccine was prescribed and is medically necessary.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  In addition, vaccines may qualify for coverage under Medicare Part B. 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 Shingrix vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets prescribed to prevent a pulmonary embolism. 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 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 being provided by the plan at the cost sharing level of Tier 3. There are no brand name drugs in the lower cost-sharing tiers to treat your condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Esomeprazole Magnesium DR 40 milligram capsules prescribed for gastroesophageal reflux disease. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Esomeprazole Magnesium is a generic drug on Tier 3 of the plans formulary. The prescribing physician has not sufficiently addressed why all of the generic drugs of the same type on the lower tiers of the plans formulary to treat the enrollees condition have been tried and failed, or are contraindicated.  A physician reviewed your appeal and determined that the plan is not required to cover the Esomeprazole Magnesium  DR capsules at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Androgel 1.62% prescribed for hypogonadism. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation supports the drug was prescribed for the enrollees diagnosis of hypogonadism. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% gel prescribed as directed to treat hypogonadism, male. 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 records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover the Testosterone gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Fentanyl 100 microgram/72-hour transdermal patches 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. We also researched Medicare systems and reviewed the enrollment data available. The record shows that the prescribed medication would result in an accumulated opioid morphine milligram equivalent dose per day of 256 milligrams per day. Your plan's formulary has a quantity limit that limits the amount of opioid you can have on hand. The quantity limit applies when dispensing of the requested opioid would result in you having 200 mg or more morphine equivalents on hand per day. The documentation does not support exceeding the morphine milligram equivalent dose per day quantity limit as outlined in the plans formulary.A physician reviewed your appeal and determined that the plan is not required to cover the Fentanyl 100 microgram/72-hour transdermal patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 5 milligram tablets, 90 tablets per 30 days.  At initial determination and redetermination the diagnosis of skeletal muscle spasm, chronic back spasms and chronic back pain.was given. The Part D plan denied the request stating that the provided diagnoses are non-medically accepted indications.  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.At reconsideration a diagnosis of acute skeletal muscle spasms of her back.was given in a letter dated March 22, 2021. No medical records were provided by the prescriber that supported this diagnosis change. This drug has been in use chronically since at least April of 2020. It could not be determined if the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 100 milligram tablets to treat other fatigue, multiple sclerosis and restless leg syndrome. The Part D plan denied the request stating that prior authorization criteria were not met.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnoses represents an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Keppra 1,000 milligram oral tablet. The Part D Plan denied your request for a tiering exception because the requested drug is non-formulary. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Keppra is a brand drug that is not listed on your plans formulary. Per Medicare rules, a tiering exception is not allowed for a drug that is not listed on the plans formulary. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 10 milligram tablets, 90 tablets per 30 days. 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 indicates that Cyclobenzaprine Hydrochloride is being prescribed for muscle spasms related to multiple chronic skeletal conditions, including degenerative disc disease, mild to moderate scoliosis, facet disease, foraminal stenosis, spinal bone spurs, and disc bulging. However, the Medicare approved compendia do not contain any citations to support the use of Cyclobenzaprine Hydrochloride for the treatment of muscle spasms related to chronic skeletal conditions. Therefore, the requested 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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol to treat cerebral atherosclerosis. The Part D plan denied the request. The requested drug is not on the plans formulary. 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. 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 Azopt 1% eye drops prescribed three times daily for the enrollees condition. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Azopt is a brand drug on Tier 4 of the plans formulary. Your doctor submitted a supporting statement. The statement did not address why all alternative lower-tier medication on the plans formulary would not work for you. All brand drugs on lower tiers have not been tried. 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.