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

You requested reimbursement for the Shingrix vaccine prescribed for shingles prophylaxis. 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 supports you received the Shingrix vaccine as a preventative measure for shingles. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Zoster vaccine recombinant, adjuvanted (Shingrix(R)) is indicated in adults 50 years or older for the prevention of herpes zoster infection (shingles). A physician reviewed your appeal and determined that the plan is required to reimburse you for the Shingrix vaccine. The vaccine is medically necessary for shingles prevention and you have provided evidence that you have paid for the vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Doxercalciferol 1 microgram capsules prescribed for secondary hyperparathyroidism of renal origin. 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. Medicare records indicate the enrollee has end stage renal disease coverage and is currently receiving dialysis. Drugs used for end stage renal disease enrollees receiving renal dialysis would be available under Medicare Part B, as these drugs are included in the Medicare Part B bundled payment to an end stage renal disease dialysis facility. Drugs covered under Medicare Part B are not available for coverage under Medicare Part D.We determined that the Medicare Part D plan is not required to cover 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

You requested Azathioprine 50 milligram tablet prescribed for retroperitoneal fibrosis. 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 Azathioprine to treat your retroperitoneal fibrosis. 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 Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablet. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is not included on your plans formulary. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methadone 40 milligrams for the treatment of addiction. The Part D Plan denied your request. We requested 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 Part D does not cover Methadone when used for treatment of opioid dependence because it cannot be dispensed for this purpose upon a prescription at a retail pharmacy. The record shows that Methadone will be obtained from a treatment center and it was not dispensed upon a prescription at a retail pharmacy. Therefore, Methadone is not eligible for Part D coverage.We determined that the plan is not required to reimburse you for the Methadone. 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

You requested Coreg CR (Carevdilol Phosphate extended-release) 10 milligram extended-release 24-hour capsules prescribed for hypertension and tachycardia. 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 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.You requested Coreg CR 10 milligram extended-release 24-hour capsules. The Part D plan denied your request stating that the formulary exception requirements were not met. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary 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.A physician reviewed your appeal and determined that the plan is not required to cover Coreg CR 10 milligram extended-release 24-hour capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gleostine 100 milligram capsules prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the list, the manufacturer, Nextsource Biotechnology, LLC, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Gleostine. 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

You requested prior authorization for Humira (CF) 40 milligram/0.4 milliliter syringe kit prescribed as directed for inflammatory 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 Humira (CF) syringe kit to treat your inflammatory arthritis. 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 (CF) syringe kit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Potassium Citrate-Citric Acid Solution 1100-334 milligram/5 milliliters prescribed three times daily for history of urinary calculi. 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 Potassium Citrate-Citric Acid Solution to treat your history of urinary calculi. Potassium Citrate-Citric Acid Solution has not been approved by the Food and Drug Administration. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to cover Potassium Citrate-Citric Acid Solution. Your request for a formulary exception was not reviewed. We cannot consider a formulary exception for a drug for which the Medicare Part D plan is unable to provide coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 5 milligram tablet prescribed for diabetes mellitus and chronic kidney 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. 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 prescribers statement does not support why 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 Farxiga.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Albuterol Sulfate 2.5 milligram per 3 milliliter nebulizer solution prescribed for the treatment of chronic obstructive pulmonary disease. 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 Albuterol Sulfate solution is going to be administered via nebulizer. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as a nebulizers. 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 requested drug. 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. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nicotine Patch 7 milligrams per 24 hours. 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. 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. 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 Sildenafil 20 milligram tablet prescribed for pulmonary arterial hypertension. 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 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. Your medical records show your doctor prescribed Sildenafil to treat your pulmonary arterial hypertension. 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 Sildenafil. 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 Abrilar Jarabe 10 milliliter liquid prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse you for Abrilar Jarabe because it was purchased in Honduras. Drugs purchased outside of the United States are excluded from coverage. 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

You requested Ansiokrol capsule prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse you for Ansiokrol because it was purchased in Honduras. Drugs purchased outside of the United States are excluded from coverage. 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

You requested Aspirin 81 milligram tablet prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse you for Aspirin because it was purchased in Honduras. Drugs purchased outside of the United States are excluded from coverage. 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

 You requested Cebion T Gramo Naranja 10 tablet prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse you for Cebion T Gramo Naranja because it was purchased in Honduras. Drugs purchased outside of the United States are excluded from coverage. 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

You requested Cinaflox 500 milligram tablet prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse you for Cinaflox because it was purchased in Honduras. Drugs purchased outside of the United States are excluded from coverage. 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

You requested Clemboxil Compuesto JBE 20 milliliter prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse you for Clemboxil Compuesto JBE because it was purchased in Honduras. Drugs purchased outside of the United States are excluded from coverage. 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

You requested Clonadex Colirio 10 milliliter prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse you for Clonadex Colirio because it was purchased in Honduras. Drugs purchased outside of the United States are excluded from coverage. 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

You requested Coldex 20 milliliter prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse you for Coldex because it was purchased in Honduras. Drugs purchased outside of the United States are excluded from coverage. 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

You requested Collistat 40 milligram prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse you for Collistat because it was purchased in Honduras. Drugs purchased outside of the United States are excluded from coverage. 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

You requested Cyclo 3 Forte capsule prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse you for Cyclo 3 Forte because it was purchased in Honduras. Drugs purchased outside of the United States are excluded from coverage. 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

You requested Cyclo Forte capsule prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse you for Cyclo Forte because it was purchased in Honduras. Drugs purchased outside of the United States are excluded from coverage. 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

You requested Digestomen Complex 10 gram tablet prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse you for Digestomen Complex because it was purchased in Honduras. Drugs purchased outside of the United States are excluded from coverage. 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.