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

You requested Inpen 100 Blue Novo Device. 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 item at issue is not directly related to the administration of insulin. 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

At issue is Lidocaine 5% patch prescribed for sacroiliitis. 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 shows the doctor prescribed Lidocaine 5% patch to treat the enrollees sacroiliitis. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Enoxaparin Sodium 100 milligrams per milliliter solution for injection to treat portal vein thrombosis. 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.Enoxaparin Sodium is a generic drug on Tier 4 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dextroamphetamine-Amphetamine extended-release 20 milligram capsules prescribed to treat attention deficit hyperactivity disorder. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Dextroamphetamine-Amphetamine extended-release 20 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Mycophenolic Acid 180 milligram delayed release tablets prescribed for renal transplant rejection prophylaxis. The Part D plan denied the request stating that the enrollees transplant was covered by Medicare; therefore, coverage for the requested drug would be available under Medicare Part B.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 Medicare Health Insurance Master Record (HIMR) system does not show that the enrollee received a Medicare-covered transplant. Additionally, documentation has been submitted by the prescriber and enrollee to validate that the transplant was covered by a private insurance company. Therefore, since the records support that the enrollees transplant was not covered by Medicare, coverage of the requested drug would be available under the Part D plan. However, Part D sponsors are responsible for ensuring that a covered Part D drug is being prescribed for a medically accepted indication. As outlined in the Medicare approved compendia, the use of Mycophenolic Acid delayed release tablets for renal transplant rejection prophylaxis is an acceptable use when the drug is being used in combination with cyclosporine and corticosteroids. However, the submitted documentation does not include any medical records.During this review, a prescriber statement and medical records were requested from the prescribers office, once by fax and once by phone. However, no medical records were submitted to validate that the enrollee was taking the requested drug in combination with cyclosporine and corticosteroids. Therefore, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested 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 Welchol 625 milligram tablet prescribed to treat irritable bowel syndrome with diarrhea. 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 Welchol was prescribed to treat irritable bowel syndrome with diarrhea. 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 Welchol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Accu-Chek Aviva Plus blood glucose test strips prescribed for type 2 diabetes mellitus. The Part D plan your 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.Blood glucose test strips are classified by Medicare as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as blood glucose test strips. Coverage under Part D is excluded for any drug or item for which payment would be available under Part B. We determined that the Medicare Part D plan is not required to cover the test strips. This decision does not address the medical necessity or appropriateness of the item. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit your request for coverage to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyzulta 0.024 percent eye drops prescribed as directed for the enrollees condition. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Vyzulta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levothyroxine 0.075 milligram prescribed for unknown diagnosis. The Part D plan approved your request.We received a 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 record shows you received Levothyroxine during an inpatient hospital stay. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plan provided documentation showing the drug was approved for coverage. Therefore, we determined that the plan is not required to reimburse you for the Levothyroxine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Ferrous Sulfate 324-milligram tablets. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. Drugs prescribed that are available over the counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.We determined that the plan is not required to cover Ferrous Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine 5% ointment, 100 grams per 30 days. The Part D plan denied the request for coverage because the amount requested exceeded the plans quantity limits. Additionally, the medication was being used for a non-medically accepted indication.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% ointment has been prescribed for neuropathic pain associated with Sjogrens syndrome. 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. Since the drug is not eligible for coverage under Medicare Part D, the plans quantity limits are not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover the requested medication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Xyosted 75 milligram per 0.5 milliliter subcutaneous auto injection pen. 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 prescriber has indicated that Xyosted has been prescribed for the treatment of unspecified testicular hypofunction and unspecified male hypogonadism. The product label available at drugs@fda states, 'XYOSTED (testosterone enanthate) injection is an androgen indicated for testosterone replacement therapy in adult males for conditions associated with a deficiency or absence of endogenous testosterone.'  Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 Phospha 250 Neutral 250 milligram tablet prescribed for tumor-induced osteomalacia. The Part D plan denied the 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 Phospha 250 Neutral because it is a non-prescription drug or over-the-counter drug. Nonprescription or over-the-counter drugs 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 Anoro Ellipta 62.5-25 microgram blister with device prescribed as directed. 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. Anoro Ellipta 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 Testosterone 30 milligram/actuation transdermal solution prescribed for hypotestosteronemia. 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  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 Tirosint 112 microgram capsules prescribed to treat hypothyroidism. 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.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for the Enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Tirosint 112 microgram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested reimbursement for Victoza 3-pack 18 milligram/milliliter pen. 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 information submitted at the reconsideration level. The record shows the GoodRx discount was applied to the purchase on the claim form. According to the GoodRx website (https://goodrx.com), the discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the GoodRx discount, you acknowledged and agreed that GoodRx will be treated as the primary payor with respect to the medications that you have selected to purchase through the GoodRx discount program. Therefore, the Plan is not required to cover or provide reimbursement for Victoza.To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance without applying the GoodRx discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Estradiol Valerate 20 milligram per milliliter vial for intramuscular injection prescribed for male-to-female gender dysphoria. The case was auto-forwarded by the plan.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. Estradiol Valerate is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. During this review, a request was submitted to the prescriber to address the alternative medications included in the plans formulary and to provide supporting medical records. The prescriber did not respond to the request. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eletriptan Hydrobromide 20 milligram tablet prescribed 27 tablets per 13 days for an 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 documentation shows Eletriptan Hydrobromide was prescribed for the Enrollees condition. The plan approved up to 18 20 milligram tablets for twelve months. A physician reviewed your appeal and determined that the plan is not required to cover the remaining Eletriptan Hydrobromide, as a diagnosis was not provided to establish Eletriptan Hydrobromide is being prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablet prescribed for diverticulitis. 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 Xifaxan was prescribed to treat diverticulitis. However, the Medicare approved compendia do not support the use of this drug for the Enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Otezla 30 milligram tablets prescribed for plaque psoriasis. 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 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. Otezla is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition 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 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 a request for coverage of Cyclobenzaprine Hydrochloride 10 milligram tablets, 270 tablets per 90 days. 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 and the enrollees claim history indicate that Cyclobenzaprine Hydrochloride is being used long-term for muscle spasms and pain due to chronic cervicalgia. The prescriber has noted at reconsideration that the enrollee also uses the drug to help with sleep. 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 conditions. Therefore, the drug is being prescribed for non-medically accepted indications 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 a request for coverage of Dupixent 300 milligram per 2 milliliter subcutaneous injection pen prescribed for bullous pemphigoid. The Part D plan denied the request because the plans prior authorization requirements were not met due to the provided diagnosis.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.As outlined in the Medicare approved compendia, the use of Dupixent has been granted an orphan drug designation by the Food and Drug Administration for the treatment of bullous pemphigoid. Therefore, the use of Dupixent in the treatment of bullous pemphigoid is a medically accepted indication. However, the documentation does not include any medical records from the prescriber to validate the diagnosis of bullous pemphigoid. During this review, a request was submitted to the prescriber to provide supporting medical records to confirm the enrollees diagnosis. However, the prescriber did not respond. Without confirmation of the diagnosis with medical records, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested 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 Temazepam 15 milligram capsule prescribed for insomnia. 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.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.