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

At issue is Tacrolimus 0.5 milligram capsule prescribed daily for anti-rejection of stem cell transplant. 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. We determined that the plan is not required to cover the Tacrolimus 0.5 milligram capsule. The beneficiary underwent a stem cell transplant, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and the requested drug is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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 Dupixent 300 milligrams/2-milliliter solution pen injector prescribed as directed for bullous pemphigoid. 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 Dupixent to treat your bullous pemphigoid. 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 Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclophosphamide 50 milligram capsule prescribed to treat multiple myeloma. 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. Cyclophosphamide 50 milligram capsule is prescribed to treat multiple myeloma. Oral-cancer drugs that were once available only in an injectable form, being administered by you or the doctor, and is being used to treat cancer, are not eligible for coverage under Part D drug benefits. However, this drug may be covered under Medicare Part B benefits. We determined that the plan is not required to cover Cyclophosphamide 50 milligram capsule under Part D drug benefits.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Dupixent 300 milligram/2 milliliter pen prescribed for bullous pemphigold. 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. The prescriber indicates Dupixent is prescribed to treat bullous pemphigold. This drug has an orphan drug designation for the treatment of bullous pemphigold. A physician reviewed your appeal and determined that the plan is required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus Solostar 100 milliliter (3) insulin pen for unknown diagnosis. The Part D plan denied the enrollees 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 plan submitted documentation that shows the enrollee submitted a claim for date of service March 8, 2021 for the requested drug. However, a claim for date of service March 17, 2021 had already processed through the plan and was paid. According to the plans Evidence of Coverage, limits and restrictions are placed on drugs that are refilled too soon. Therefore, the claim for fill date March 8, 2021 does not qualify for reimbursement, as it was considered refilled too soon. We determined no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Privigen 10% intravenous solution prescribed 80 grams every three weeks for long term treatment of myasthenia gravis without acute exacerbation. 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.The documentation shows the doctor prescribed Privigen 10% to treat the enrollees myasthenia gravis without acute exacerbation. 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 Privigen 10%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a compound drug containing Azathioprine Powder 125 milligram, Sodium Bicarbonate Powder, and an empty capsule size 3 clear compound prescribed for Behcets syndrome. 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. The requested compounded medication does not contain any ingredients that meet the definition of a Part D drug. Bulk powders are not approved by the food and drug administration and are therefore not covered under Part D.A physician reviewed your appeal and determined that the plan is not required to cover Azathioprine Powder compounded capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Yuvafem 10 microgram vaginal insert prescribed three times per week for atrophic vaginitis. 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. A physician reviewed the appeal and determined that the plan is not required to cover Yuvafem 10 microgram vaginal insert.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for a tiering exception for Levemir Flextouch 100 unit/milliliter.  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. This includes the case file from the plan and any information submitted at the reconsideration level. Levemir Flextouch is a brand drug on Tier 3 of the plans formulary. Your doctor did not address why the other drug available on the lower tier of your plans formulary would not work for you. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for FNovolog 100 units per milliliter solution pen-injector prescribed to inject 7 units subcutaneous three times daily to treat type II diabetes.  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 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.Novolog is a brand drug on Tier 3 of the plans formulary. There were no medical records provided to support that all drugs available on lower tiers to treat the enrollees condition have been tried or deemed contraindicated. 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

You requested Fetzima ER 40 milligram capsules prescribed as directed for dysthymic 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 Fetzima ER to treat your dysthymic 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 Fetzima ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dalfampridine 10 milligram extended release tablet prescribed for management of dizziness, nystagmus, and vertigo. 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. Dalfampridine 10 milligram extended release tablet is prescribed for the management of dizziness, nystagmus, and vertigo. However, Medicare approved compendia do not support the use of this drug for this condition.  A physician reviewed your appeal and determined that the plan is not required to cover Dalfampridine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement of Sutab tablet. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. . However, we did not receive the documentation. 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, we did not receive a prescribers statement or medical records to support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to reimburse Sutab.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Addyi 100 milligram tablet prescribed daily for sexual dysfunction. 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. We determined that the plan is not required to cover Addyi because it was used to treat sexual dysfunction. Drugs prescribed for the treatment of sexual dysfunction are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, they must pay for them. 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 Diphenhydramine 25 milligram capsule prescribed for unknown diagnosis. The Part D plan denied the reimbursement request.   We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and does not qualify for reimbursement.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a prior authorization request for Ubrelvy 50-milligram tablets prescribed for migraine headaches. The Part D plan denied coverage.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 records submitted at the reconsideration level. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee satisfies the plan's prior authorization coverage criteria. We received the requested information and included it in the review.The submitted documentation includes a prescriber statement. The prescriber statement indicates the drug at issue was prescribed for the noted condition. The Medicare approved compendia support the use of the drug for the noted condition. Furthermore, the prescriber has indicated the enrollee has had an inadequate treatment response with a triptan 5-HT1 receptor agonist. The submitted documentation supports the enrollee has met the plans prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cayston 75 milligram solution for reconstitution prescribed for chronic lower respiratory tract infection in the setting of persistent pseudomonas infection, impaired airway clearance and dysphagia with aspiration resulting in chronic pulmonary soilage. 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. Cayston 75 milligram solution for reconstitution is prescribed to treat chronic lower respiratory tract infection in the setting of persistent pseudomonas infection, impaired airway clearance and dysphagia with aspiration resulting in chronic pulmonary soilage. However, Medicare approved compendia do not support the use of this drug for this condition.  A physician reviewed your appeal and determined that the plan is not required to cover Cayston 75 milligram solution for reconstitution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Folic Acid 1 milligram tablet to treat anemia. The Part D plan denied the request.   We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed for use as vitamins and minerals are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Octagam 5 grams per 50 milliliters solution prescribed to treat the enrollee with necrotizing myopathy. The Part D plan denied the appeal 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 Octagam 5 grams per 50 milliliters solution to treat necrotizing myopathy. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Octagam 5 grams per 50 milliliters solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acetaminophen 325 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request.   We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acetaminophen 500 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request.   We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alphagan P 0.1% eye drops prescribed for unknown diagnosis. 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.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the requested drug was purchased. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined this drug was paid correctly and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amitriptyline Hydrochloride 10 milligram tablet prescribed for unknown diagnosis. 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.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the requested drug was purchased. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined this drug was paid correctly and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin EC 81 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request.   We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Biscodyle EC 5 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request.   We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dicyclomine 10 milligram capsule prescribed for unknown diagnosis. 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.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the requested drug was purchased. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined this drug was paid correctly and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dok 100 milligram softgel prescribed for unknown diagnosis. The Part D plan denied the request.   We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dorzolamide Hydrochloride 2% eye drops prescribed for unknown diagnosis. 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.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the requested drug was purchased. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined this drug was paid correctly and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrochlorothiazide 25 milligram tablet prescribed for unknown diagnosis. 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.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the requested drug was purchased. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined this drug was paid correctly and no reimbursement is required by the plan.