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

You requested Methocarbamol 500 milligram oral tablet prescribed daily for muscle spasms of the back. 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 Methocarbamol to treat your chronic muscle spasms of the back. 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 Methocarbamol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Crestor 20 milligram tablets prescribed daily for atherosclerosis of aorta in an enrollee with hyperlipidemia. The Part D plan denied your request because the documentation did not support an off-formulary 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. 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 the Crestor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Lisinopril 10 milligram tablets. 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 documentation requested.The documentation submitted does not include medical records indicating the condition for which this drug was prescribed. As such, we cannot reimburse you for the drug until it can be determined that it was medically necessary for your condition.A physician reviewed your appeal and determined that the plan is not required to reimburse you for Lisinopril.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trospium Chloride 60 milligram extended-release oral capsule prescribed daily for overactive bladder. 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 Trospium Chloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humalog Kwikpen u-100 100/milliliter insulin pen. 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. This drug is included on Tier 6 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: Favorable

At issue is Torsemide 10 milligram tablets prescribed to treat essential hypertension.   The Part D plan denied the request.  The requested drug is not on the plans formulary. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The physician sent a statement dated 4/21/2021 indicating the enrollee had tried and failed both furosemide and bumetanide as the enrollee experienced a rash and shortness of breath with those drugs. The prescriber has provided patient specific clinical rationale as to why two other formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Cepacol lozenge 15 milligram/2.6 milligram. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we 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 Cepacol lozenge.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Adderall 10 milligrams prescribed daily for excessive daytime sleepiness. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. 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 Adderall for excessive daytime sleepiness. In review of the Medicare approved compendia, excessive daytime sleepiness is not a medically accepted indication for Adderall. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Adderall at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Levemir Flextouch pen 100 units/milliliter solution prescribed for diabetes. The Part D plan denied your request for a tiering exception because Levemir Flextouch pen is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Levemir Flextouch pen is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 50 milligram tablet prescribed daily 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.Myrbetriq ER 50 milligram tablet 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

You requested a tiering exception for Shingrix 50 micrograms/0.5 milliliter vaccine prescribed for the enrollee. The Part D plan denied your request for a tiering exception because Shingrix is a brand name Tier 3 drug and the lower cost-sharing tiers do not contain any alternative drugs for your condition. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The plan shows Shingrix is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Ozempic 1 milligram pen injector prescribed for type 2 diabetes. We received an auto-forwarded reconsideration request from the coverage level.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. The plan shows Ozempic is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a 90-day supply of Xcopri 100 milligram tablet prescribed for partial onset seizures. 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 a 90-day supply of Xcopri for seizures. The plan approved a recurring 30-day supply of Xcopri. The plan limits the amount of Xcopri to a 30-day supply. Your doctors statement does not support why an exception to the plans quantity limit is medically necessary.  Also note that relevant medical records were requested and were not provided.  A physician reviewed your appeal and determined that the plan is not required to cover the additional  60-day supply of Xcopri, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 1% gel. 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 Diclofenac Sodium gel was prescribed to treat your degenerative bone disease, plantar fasciitis, and scoliosis. 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 Diclofenac Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Santyl 250 unit/gram ointment prescribed for a severe skin wound. The Part D plan denied your request for a tiering exception because Santyl is a biologic Tier 4 drug and the lower cost-sharing tiers do not contain any alternative drugs for your condition. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Santyl is a biologic Tier 4 drug. There are no biologic drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 290 micrograms capsule prescribed for the diagnosis of idiopathic chronic constipation.. 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.Linzess 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

You requested Insulin Aspart 100 units per milliliter prescribed for type 1 diabetes. The Part D plan did not make a decision.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.The record shows you received Insulin Aspart for administration through an insulin pump. However, this drug is eligible for coverage under Medicare Part B. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.We determined that the plan is not required to reimburse Insulin Aspart.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked for reimbursement for Solifenacin 10 milligram tablets. The Part D plan did not provide a timely decision. 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 information provided does not include a receipt showing the amount was paid. There are only amounts showing as due on the documents. A physician reviewed your appeal and determined that the plan is not required to reimburse the amount for Solifenacin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Norvasc 10 milligram tablets prescribed for 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 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 and medical record do not support why other drugs on the plans formulary would not work for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Norvasc.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tymlos 80 micrograms/ dose pen-injector prescribed for the diagnosis of postmenopausal osteoporosis. 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 Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested TPN electrolytes concentrate prescribed for the treatment of short bowel syndrome. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows TPN electrolytes concentrate is being administered to the enrollee intravenously in the home for permanent dysfunction of the gastrointestinal tract. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment, if the equipment used in the patients home. Payment may be made for supplies necessary for the effective use of DME, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. We determined that the Medicare Part D plan is not required to cover Total parenteral nutrition electrolytes concentrate. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle lite blood glucose test strips prescribed for the treatment of diabetes. 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. We determined that the plan is not required to cover or reimburse you for the Freestyle lite blood glucose test strips. Medicare rules state drugs that are not considered a medical supply directly associated with the injection of insulin are not covered under Part D. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. 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 Altace 10 milligram capsules prescribed as directed for hypertension. The Part D plan denied your request because the documentation did not support an off-formulary 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. 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

You requested reimbursement of Potassium Chloride Extended Release 10 milliequivalent tablets. 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. A request was sent to your prescriber for additional information including the diagnosis that the drug is being prescribed for. We have not received a response. The documentation was insufficient to determine if the drug is prescribed for a medically accepted indication and if the drug is eligible for Part D coverage.  A physician reviewed your appeal and determined that the plan is not required to cover reimbursement of Potassium Chloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Saxenda 18 milligrams per 3 milliliter prescribed daily for obesity. 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.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 doctor prescribed Saxenda to treat your obesity. 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 you have satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Saxenda. 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 Ipratropium-albuterol 0.5-3 milligrams/3 milliliters ampul prescribed for nebulization to treat the diagnosis of asthma. The Part D plan denied the request because drugs that could be covered under Medicare Part A or B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows that Ipratropium-albuterol is being administered at home via a nebulizer. Based on the information provided, we have determined the requested drug is not eligible for Medicare Part D coverage, but may be covered under Part A or B benefits.We determined that the plan is not required to cover Ipratropium-albuterol, as this drug is not eligible for Medicare Part D coverage.