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

You requested Methylphenidate Hydrochloride ER 10 milligram tablets prescribed for major depressive disorder recurrent, unspecified, dysthymic disorder, obesity, unspecified and polyphagia. 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 Methylphenidate Hydrochloride to treat your major depressive disorder recurrent, unspecified, dysthymic disorder, obesity, unspecified and polyphagia. 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 Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levemir 100 units per milliliter prescribed for diabetes. The Part D plan did not make a decision.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. Levemir 100 units per milliliter 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 Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed for chronic neck pain, cervical stenosis, and radiculopathy. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows your doctor prescribed Cyclobenzaprine Hydrochloride to treat your chronic neck pain, cervical stenosis, and radiculopathy. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Novolog 100 units/milliliter vial prescribed for the enrollees condition. 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. Novolog is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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 Soliqua 100 units-33 microgram/milliliter pen prescribed for the enrollees condition. 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. Soliqua is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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 Trulance 3 milligram tablets prescribed daily for constipation. 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. 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.A physician reviewed your appeal and determined that the plan is not required to cover Trulance.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligram per milliliter solution prescribed for your condition. The Part D plan did not make a decision.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. Prolia 60 milligram per milliliter solution is a brand drug on Tier 4 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 Premarin Vaginal cream applicator prescribed for the enrollees condition. 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 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 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 Humira 80 milligrams/0.8 milliliter pen injector prescribed for granuloma annulare. 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 Humira for granuloma annulare. 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 Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80 milligram per milliliter auto-injector prescribed for severe plaque psoriasis. 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 medical records show your doctor prescribed Taltz to treat your severe plaque psoriasis. 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 Taltz.  The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dupixent 300 milligram per 2 milliliter prefilled syringe prescribed daily for epidermolysis bullosa, unspecified. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Dupixent to treat epidermolysis bullosa caused by plectin mutation. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Alogliptin 12.5 milligram tablet prescribed while you were in the hospital outside of the United States. 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 the plans Evidence of Coverage, drugs purchased outside the United States and its territories are not covered. We determined that the plan is not required to cover the Alogliptin or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amlodipine 10 milligram tablet prescribed while you were in the hospital outside of the United States. 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 the plans Evidence of Coverage, drugs purchased outside the United States and its territories are not covered. We determined that the plan is not required to cover the Amlodipine or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Duloxetine 60 milligram tablet prescribed while you were in the hospital outside of the United States. 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 the plans Evidence of Coverage, drugs purchased outside the United States and its territories are not covered. We determined that the plan is not required to cover the Duloxetine or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Glipizide 5 milligram tablet prescribed while you were in the hospital outside of the United States. 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 the plans Evidence of Coverage, drugs purchased outside the United States and its territories are not covered. We determined that the plan is not required to cover the Glipizide or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Saxenda 18 milligram/3 milliliter pen injector prescribed for morbid obesity. The Part D plan denied your request because Medicare has excluded Part D coverage for drugs used for the treatment of weight gain. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We determined that the plan is not required to cover Saxenda. Drugs used to treat weight gain (promote weight loss) 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 Tizanidine Hydrochloride 6 milligram tablets prescribed twice daily for muscle spasms. 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, or drug strengths, on the plans formulary would not work for you. For informational purposes only, Tizanidine 2 milligram and 4 milligram tablets are on the plan's formulary.A physician reviewed your appeal and determined that the plan is not required to cover Tizanidine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vemlidy 25 milligram tablets prescribed for chronic viral hepatitis B without delta-agent. 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

You requested a formulary exception for Armodafinil 250 milligram tablets prescribed for daytime somnolence, depression, and fatigue related to non-Hodgkin's lymphoma. 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 Armodafinil to treat your daytime somnolence, depression, and fatigue related to non-Hodgkin's lymphoma. 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 Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 1 percent gel prescribed for chronic pain, radiculopathy, cervical region. 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 Sodium 1 percent gel to treat your chronic pain, radiculopathy, cervical region, other axial spine pain, and myofascial pain syndrome 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 Sodium 1 percent gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% Patch to treat dorsalgia, unspecified. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Januvia 50 milligram tablets prescribed for type 2 diabetes without complications. 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. Januvia is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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 Diclofenac Sodium 1 percent gel prescribed for autoimmune inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, IBD-associated arthritis, and reactive 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 shows your doctor prescribed Diclofenac Sodium 1 percent gel to treat your autoimmune inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, IBD-associated arthritis, and reactive arthritis). However, the Medicare approved compendia do not support the use of this drug, as prescribed, for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium 1 percent gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tremfya 100 milligram/milliliter injector prescribed for psoriasis. 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 De3-Dry Eye Omega Benefits prescribed for dry eye syndrome. The Part D plan did not make a decision.We performed and 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 reimburse De3-Dry Eye Omega Benefits because it is a prescription vitamin and mineral product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol HFA 90 microgram inhaler, 30 day supply prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows you were in the initial coverage stage of the Part D benefit when this drug was purchased. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The record shows the plan paid its share of the cost for the Albuterol and the remaining amount was your copay for a tier 2 drug filled at a mail order pharmacy. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Terazosin hydrochloride 2 milligram capsules, 40 day supply prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows you were in the initial coverage stage of the Part D benefit when this drug was purchased. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The record shows the plan paid its share of the cost for the Terazosin hyrdrochloride and the remaining amount was your copay for a tier 2 drug filled at a mail order pharmacy. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Patch 5%. 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 requested information from your prescriber to verify the diagnosis that requires treatment with the Lidocaine Patch 5%. We did not receive a response. It was unable to be determined if the drug is being prescribed for a medically accepted indication as supported by the Medicare approved compendia. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine Patch 5%.