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

At issue is Ibrance 125 milligram tablet prescribed daily for 21 days for breast cancer. 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.The documentation supports your doctor prescribed Ibrance to treat your breast cancer. 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 Ibrance. There is insufficient documentation to determine if the prior authorization requirements have been met. The physician has not indicated if this is a new start therapy or if you have used the drug before. In addition, a diagnosis of human epidermal growth factor receptor 2 (HER2)-negative breast cancer is required by the plan. 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 Motegrity 1 milligram tablet prescribed for treatment resistant gastroparesis. 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 and other documentation to show why you need this medication. We did not receive the documentation requested. The documentation shows your doctor prescribed Motegrity to treat your treatment resistant gastroparesis. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, a formulary exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Motegrity.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a quantity limit exception for Silodosin 8 milligram capsules. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates your doctor requested 30 capsules for a 365 days. Your plan does not allow greater than a 30-day or 90-day supply of prescription medication. Therefore, a quantity limit exception cannot be granted and the amount approved by the plan is upheld.Therefore, the plan is not required to cover Silodosin for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Praluent 75 milligram per milliliter pen-injector. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.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

At issue is Neupro 4 milligram/24 hour patch. 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. Neupro 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 Myrbetriq 50 milligram extended-release oral tablet. 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. Myrbetriq 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. 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. The submitted documentation does not contain medical records to support a covered diagnosis. A request for information was sent to your physician; however, no documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a prior authorization for Zolpidem Tartrate 10 milligram tablets. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not contain medical records to support a prescribed diagnosis. A request for information was sent to the prescriber; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate Hydrochloride 10 milligram tablets prescribed for major depressive disorder. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates your doctor prescribed Methylphenidate Hydrochloride for major depressive disorder. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amitriptyline Hydrochloride 10 milligram tablets prescribed daily for vulvodynia. The Part D plan denied your request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The documentation shows your doctor prescribed Amitriptyline Hydrochloride to treat your vulvodynia. 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 Amitriptyline Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humira 40 milligram/0.8 milliliter syringe with a quantity of 90 days supply. The Part D plan approved a 30 day supply but denied the request for a 90 day supply as the drug is limited to a recurring 30 day supply. 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 including a diagnosis and medical records or other documentation to show why you need this medication. No documents were received. A physician reviewed your appeal and determined that the plan is not required to cover a 90 day supply of Humira 40 milligram/0.8 milliliter syringe.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin 10 milligram tablet prescribed for low back pain, lumbar radiculopathy, and lumbar spinal stenosis. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation. The documentation shows your doctor prescribed Oxycontin to treat your low back pain, lumbar radiculopathy, and lumbar spinal stenosis 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 your appeal and determined that the plan is not required to cover Oxycontin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathioprine 50 milligram tablets prescribed daily following a liver transplant. The Part D Plan denied the request.  We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Based on the information provided, the drug is eligible for Part B 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 Saxenda 18 milligram/3 milliliter pen injector prescribed for weight loss. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Saxenda because it was prescribed for weight loss. Drugs to treat anorexia, weight loss, or weight gain 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 Tamazepam 15 milligram capsules. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any 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 Tamazepam 15 milligram capsules. The Part D plan denied your request stating that the prior authorization criteria was not satisfied. However, there were no medical records submitted supporting your condition. The QIC is unable to determine if your condition is a medically accepted indication to support the use of the requested drug.A physician reviewed your appeal and determined that the plan is not required to cover Tamazepam 15 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Daliresp 500 microgram oral 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 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 Daliresp to treat chronic obstructive pulmonary disease with recurrent exacerbation. 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 Daliresp. 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 Mycophenolate Mofetil 500 milligram tablets prescribed for respiratory bronchiolitis interstitial lung disease. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not include medical records to support a covered diagnosis. A request for information was sent to the prescriber; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz 5 milligram tablet prescribed twice daily for atopic dermatitis and atopic keratoconjunctivitis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read all documentation submitted. This includes any information submitted at the reconsideration level. The documentation shows the doctor prescribed Xeljanz to treat the enrollees atopic dermatitis and atopic keratoconjunctivitis. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Hydrocodone/Acetaminophen 10-325mg tablet to treat chronic pain syndrome. 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.The record shows you were prescribed Hydrocodone/Acetaminophen 10-325 milligram tablet to treat your chronic pain syndrome. We asked the prescriber to send us answers to the prior authorization request, a prescriber statement, and confirmation that the pain is severe enough to require daily, around-the-clock, long-term opioid treatment. Additionally, that the patient is not opioid naive, an attestation of the history of previous tried and failed drugs, and attestation that the enrollee is counseled on the potential adverse effects of opioid analgesics. We received the documentation and included it in our review.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

You requested Budesonide 0.5 milligram/2 milliliter nebulizer solution. The Part D plan denied the 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 drug at issue is for use in a nebulizer in the enrollees home. This is eligible for coverage under Part B. 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 Sodium Chloride 0.9% solution prescribed for unknown diagnosis. The Part D plan denied your request. We received the case to perform an independent and de novo review. e reviewed all documentation submitted. A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Xifaxan 550 milligram tablets. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Xifaxan has been prescribed for small intestinal bacterial overgrowth with associated gaseous abdominal distension and heartburn. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets. 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. We also researched Medicare systems and reviewed the enrollment data available. (IF APPLICABLE)Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine 5% patches. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Lidocaine 5% patches have been prescribed for pain to the right side due to previous rib fractures and a subsequent fall. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ipratropium-Albuterol 0.5-3 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 Ipratropium-Albuterol 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 Ipratropium-Albuterol. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.