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

At issue is Lidocaine Topical Patch 5%.  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.In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, medical records supporting that medically accepted indication are required. These records were requested from the prescriber, and we did not receive information that could answer these medical necessity issues.  A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine Topical Patch 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Febuxostat 40 milligram tablets prescribed for idiopathic chronic gout of multiple sites with tophus. 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. Your medical records show your doctor prescribed Febuxostat to treat your idiopathic chronic gout of multiple sites with tophus. 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 plan's coverage criteria have been satisfied.A physician reviewed your appeal and determined that the plan is not required to cover Febuxostat. 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

At issue is Donepezil Hydorchloride 10 milligram 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. Donepezil Hydrochloride is a generic drug on Tier 2 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 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 Trelegy Ellipta 100-62.5-25 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.Trelegy 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 Linzess 145 microgram capsules 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. Linzess 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 Nuplazid 34 milligram tablets 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.Nuplazid 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 Enbrel Mini 50 milligram/milliliter solution cartridge 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. This drug is included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering 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: Unfavorable

You requested Ciproflox prescribed while you were outside of the United States. 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 the plans Evidence of Coverage, drugs purchased outside the United States and its territories are not covered. We determined that the plan is not required to cover the Ciproflox or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Electrolit prescribed while you were outside of the United States. 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 the plans Evidence of Coverage, drugs purchased outside the United States and its territories are not covered. We determined that the plan is not required to cover the Electrolit or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Enviq prescribed while you were outside of the United States. 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 the plans Evidence of Coverage, drugs purchased outside the United States and its territories are not covered. We determined that the plan is not required to cover the Enviq or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Libertrim S11 prescribed while you were outside of the United States. 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 the plans Evidence of Coverage, drugs purchased outside the United States and its territories are not covered. We determined that the plan is not required to cover the Libertrim S11 or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Popram 20 milligram prescribed while you were outside of the United States. 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 the plans Evidence of Coverage, drugs purchased outside the United States and its territories are not covered. We determined that the plan is not required to cover the Popram or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zofran RX prescribed while you were outside of the United States. 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 the plans Evidence of Coverage, drugs purchased outside the United States and its territories are not covered. We determined that the plan is not required to cover the Zofran RX or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone-Acetaminophen 10-325 milligram tablet prescribed five times daily for chronic pain, cervical myelopathy, and stenosis of cervical spine. 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 received the documentation and included it in our review.Your medical records show your doctor prescribed Hydrocodone-Acetaminophen to treat your chronic pain, cervical myelopathy, and stenosis of cervical spine. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. 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

You requested Armodafinil 150 milligram tablets prescribed as directed 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 documentation shows your doctor prescribed Armodafinil to treat your major depressive disorder. 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 Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone Acetaminophen 10-325 milligram tablets prescribed 7.5 tablets per day for atherosclerosis of native artery of left lower extremity with ulceration. 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 amount of the medication. We did not receive the documentation requested.Your medical records show your doctor prescribed Oxycodone Acetaminophen to treat your atherosclerosis of native artery of left lower extremity with ulceration. However, your medical records do not support why an exception to the plans quantity limit is medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover the Oxycodone Acetaminophen, 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 Durolane 60 milligram/3 milliliter prefilled syringe  prescribed for knee pain. 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 the Durolane will be supplied by the prescriber and administered to the enrollee in the prescribers office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Durolane. 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 Pramipexole Dihydrocholoride1 milligram tablets prescribed 3 tablets at bedtime. 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. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The record shows the total out-of-pocket was applied to your co-payment, co-insurance, or deductible amount. We determined no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix 50 microgram per 0.5 milliliter vial. 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. 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 includes valid proof of payment for reimbursement. However, there were no medical records submitted for review. In addition, no diagnosis was given at initial determination. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to reimburse Shingrix.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Famotidine 20 milligram tablets prescribed daily 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 documentation states the drug was purchased at a standard in-network pharmacy instead of the preferred mail order pharmacy. According to your plan, Famotidine 20 milligram tablet is a tier 2 drug with a copay of $42. The record shows the full price of the drug was less than the $42 copay amount. Therefore, your charge was based on the lesser amount of the two. We determined no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Restatsis Multidose Emulsion (quantity 3) prescribed for an unknown 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. The record shows you purchased Restasis from a preferred pharmacy. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benzonatate 100 milligram capsule prescribed for cough. 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.Drugs prescribed for the symptomatic treatment of cough and colds are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Polyethylene Glycol powder pack. The Part D plan denied your 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 Polyethylene Glycol because it does not require a prescription. 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: Favorable

You requested Memantine 10 milligram prescribed for unknown diagnosis. 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.The record shows you purchased Memantine from a preferred pharmacy and was charged a copay for the drug as tier 3. However, the documentation provided includes a screen-print from the plan indicating the Memantine was approved for tier 1 from January 1, 2021 through December 31, 2021. Therefore, we determined that the plan is required to reimburse you the amount of the copay for tier 3, minus any applicable tiered copayment/coinsurance amount for tier 1.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Donepezil 10 milligram prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows you purchased Donepezil from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined your copay for Donepezil was correctly calculated and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of NP Thyroid 15 milligram tablets prescribed for hypothyroidism. 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.Non-FDA approved drugs are excluded from Medicare Part D coverage.  Therefore, the requested drug is excluded from coverage.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 Chantix 1-milligram tablet to treat tobacco chew use (Z72.0). The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 NP Thyroid 15-milligram tablet to treat an unknown condition. The Part D plan denied the request. 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.Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyanocobalamin 1000 microgram/milliliter solution prescribed for unknown 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. 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. The plan indicates that Cyanocobalamin is covered under the enrollee's supplemental benefits. 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.