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

You requested Tremfya 100 milligrams/milliliter pen injector prescribed as directed to treat psoriasis vulgaris. 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 also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Tremfya.A physician reviewed your appeal and determined that the plan is not required to cover the Tremfya.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligram tablets prescribed for tumid lupus. 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 Mycophenolate Mofetil for tumid lupus. The Medicare approved compendia do not support the use of this drug for your condition. 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 reimbursement for Oxycodone-Acetaminophen 10-325 milligram tablets purchased on February 17, 2021.  The Part D plan denied forwarded the request to us for review. 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 plan requires proof of payment for reimbursement requests. You submitted a prescription label for Oxycodone-Acetaminophen that was filled on February 15, 2021, and picked up on February 17, 20201. You have submitted a receipt for $30.44 dated January 20, 2021. However, there is no receipt for the medication picked up on February 17, 2021. Therefore, we have determined that the Part D plan is not required to reimburse you for the cost of the Oxycodone-Acetaminophen tablets picked up on February 12, 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methocarbamol 750 milligram prescribed to treat the enrollees condition. We received an auto-forwarded 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 prescriber was asked to submit documentation to clarify the medical history and support the noted diagnosis. The prescriber was also asked questions to address the plans formulary alternatives. We did not receive the documentation requested.Based upon the current record, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Methocarbamol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for hearing aid charges from the date of service, November 10, 2020. The Part D plan denied the request because hearing aids and related charges are not 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. According to Medicare rules, Medicare Part B may cover care for a hearing related medical condition or diagnostic hearing tests to help a doctor assess a hearing problem. We determined that the Medicare Part D plan is not required to cover the hearing aid charges. This decision does not address the medical necessity or appropriateness of the requested item. 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 EnteraGam 5-gram Powder Packet to treat irritable bowel syndrome with diarrhea.   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.EnteraGam is considered a medical food and not considered/approved as a drug by the Food and Drug Administration. Therefore, the EnteraGam is excluded from Medicare Part D coverage and your plan is not required to reimburse you for the cost.Our physician reviewer has determined that EnteraGam is excluded from Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Aspirin 81 milligram chewable tablets. The Part D plan did not provide a timely 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. Aspirin is an over the counter item and in non-prescription. Non-prescription drugs are excluded from Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover reimbursement for Aspirin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Acetaminophen 500 milligram tablet and 325 milligram tablet. 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 Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Pantoprazole Sodium 40 milligram delayed release tablet paid out of pocket. The request was being auto forwarded for a missed turnaround. We received an auto-forwarded 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 you were billed and paid for Pantoprazole Sodium 40 milligram delayed release tablet ($11.17).  A request was submitted to provide a diagnosis, and to provide supporting medical records.  Medical records and a diagnosis were not provided.  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

You requested Gralise 600 milligram tablets prescribed three times daily for restless legs syndrome. 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 indicates your doctor prescribed Gralise for restless legs syndrome. The Medicare approved compendia do not support the use of this drug for your condition. 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 Lorazepam 1 milligram tablet prescribed as directed for anxiety. The Part D plan denied the 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.No medical records were provided by the prescriber to support the diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Lorazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Neurontin 100 milligram capsules prescribed three times daily. 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 also researched Medicare systems and reviewed the enrollment data available.  The requested drug is being provided by your plan under a formulary exception. Neurontin 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 non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Dextroamphetamine/Amphetamine 20 milligram tablets prescribed daily for chronic fatigue due to multiple sclerosis. 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 Dextroamphetamine/Amphetamine for chronic fatigue due to multiple sclerosis. In review of the Medicare approved compendium, chronic fatigue due to multiple sclerosis is not a medically accepted indication for Dextroamphetamine/Amphetamine. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Dextroamphetamine/Amphetamine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 60 milligram tablet to treat hypothyroidism. 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.Non-FDA approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clenpiq Solution prescribed for a colonoscopy bowel preparation. 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 also researched Medicare regulations and Medicare approved compendia. The plan requires prior authorization requirements be met before covering this drug. The prescriber indicates that the enrollee did not try Suprep or why this drug, required by the plan for step therapy, could not be used. The prior authorization requirements have not been met. A physician reviewed your appeal and determined that the plan is not required to cover Clenpiq Solution.
Appeal type: Prescription Drug
Decision: Partially Favorable

You requested Interferon alfa 2b  prescribed daily for neoplasm of the conjunctiva. The Part D plan partially 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 levelThe record shows the Interferon alfa 2b is a compounded drug and each ingredient is reviewed individually. Medicare Part D does not cover drugs that do not meet the definition of a Part D drug. Therefore, we determined that the plan is not required to cover or reimburse for the Sodium chloride bacteriostatic. However, we determined that the Medicare rules for the Intron A have been met. Medicare rules allow a Part D plan to manage its formulary by requiring prior authorization, step therapy or quantity limits. Prior authorization has been met for the Intron A. Therefore, the plan is required to cover and provide reimbursement for the Intron A ingredient included in the Interferon alfa 2b compound purchased March 4, 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ofioxacin .3% eye drops prescribed for cataract surgery. The Part D plan was unable to review your case timely and auto-forwarded 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 received Ofioxaxin prior to cataract surgery. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that you paid for the Ofioxaxin was not provided. Therefore, we determined that the plan is not required to reimburse you without the required documentation. Please submit proof of payment to your plan for reimbursement.
Appeal type: Prescription Drug
Decision: Favorable

You requested Multaq 400 milligram tablets 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 requested Multaq from a network pharmacy while you were in the catastrophic coverage phase of your plan. We reviewed the plans 2020 Evidence of Coverage. In this case, you paid more than your percentage or copay/coinsurance calculated in the catastrophic coverage phase for the year 2020. Therefore, we determined that the plan is required to recalculate and reimburse you for their share of the cost, less their initial reimbursement and less the copay/coinsurance amount.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement of Toujeo Solostar prescribed for diabetes. 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 regulations and Medicare approved compendia. In the case of a drug that would incur a copayment, the Part D sponsor must apply cost-sharing as calculated by multiplying the applicable daily cost-sharing rate by the number of days of the drug supply actually dispensed when the beneficiary receives less than the approved month's supply. In the case of a drug that would incur a coinsurance percentage, the Part D sponsor must apply the coinsurance percentage for the drug to the number of days of the drug supply actually dispensed. [42 CFR Section 423.153(b)(4)(iii)]The amount of the copayment or coinsurance will vary depending on the drug's tier and place of purchase. The record shows that the enrollee was charged an amount that is equal to the required copayment for the Tier 4 drug. Therefore, the amount in question is the enrollees co-pay and no reimbursement is required. A physician reviewed your appeal and determined that the plan is not required to reimburse the amount of Toujeo Solostar.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Spravato 84 milligram dose pack prescribed for major depressive disorder. 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 Spravato is being prescribed to the enrollee for treatment of depression. Medicare law specifically excludes coverage for any drug for which payment would be available under Medicare Parts A or B for that individual. Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner). Spravato is a type of drug that must be administered under direct observation of a health care provider and monitored for at least two hours after administration. The Food and Drug Administration has mandated a Risk Evaluation and Mitigation Strategy for Spravato. This strategy requires that Spravato be only dispensed and administered to patients in a medically supervised healthcare setting that monitors the enrollee. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Spravato. Please consider submitting this request to Medicare Part B. 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 Cyanocobalamin 1000 microgram/ 1 milliliter solution prescribed for Vitamin B12 deficiency. 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, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Cyanocobalamin. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Opium Tincture 10 milligrams/milliliter prescribed daily for diarrhea related to Crohns 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 record shows your physician prescribed Opium Tincture for your diarrhea related to Crohns disease. The drug at issue is not Food and Drug Administration approved. Therefore, the drug cannot be considered a Part D benefit.We determined that the plan is not required to cover the Opium Tincture.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tretinoin Cream 0.1%. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The documentation indicates that Tretinoin is prescribed to treat folliculitis. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to Tretinoin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Diovan 160 milligram tablets prescribed for the enrollees condition. 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.Diovan is a brand drug on Tier 3 of the plans formulary. Your doctor submitted a supporting statement. There are no brand drugs of the same type on the plan's formulary at a lower cost-sharing tier;  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 Buprenorphine Hydrochloride 2 milligram sublingual tablets prescribed for spinal stenosis of lumbar region without neurogenic claudication and other spondylosis. 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 Buprenorphine Hydrochloride sublingual tablets for spinal stenosis of lumbar region without neurogenic claudication and other spondylosis. The Medicare approved compendia do not support the use of this drug for your condition. 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 Gralise ER 600 milligram tablet three times daily to treat diabetic neuropathy. The Part D plan denied the 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 National Drug Code billed for the drug is not registered with the Food and Drug Administration. It may be that your pharmacy billed the wrong code. Non-approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.