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

At issue is Zaleplon 5 milligram capsule prescribed daily for long term insomnia. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Zaleplon to treat the enrollees long term insomnia. However, the Medicare approved compendia do not support the use of this drug for this long term condition. A physician reviewed your appeal and determined that the plan is not required to cover Zaleplon.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested the Freestyle Libre Reader prescribed for diabetes mellitus. 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 determined that the plan is not required to cover the Freestyle Libre Reader because it is not considered a medical supply directly associated with the injection of insulin. Although, this device 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 the Freestyle Libre Sensor prescribed for diabetes mellitus. 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 determined that the plan is not required to cover the Freestyle Libre Sensor because it is not considered a medical supply directly associated with the injection of insulin. Although, this device 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: Favorable

You requested Clobazam suspension 2.5 milligram/milliliter prescribed for new-onset refractory status epilepticus. 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 Clobazam for new-onset refractory status epilepticus. The Medicare approved compendia support the adjunct use of this drug for your condition. A physician reviewed your appeal and determined that the plan is required to cover Clobazam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spiriva Respimat 2.5 micrograms per actuation inhalation spray prescribed as directed for chronic obstructive pulmonary disease. 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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to Spiriva Respimat.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate ER 6.25 milligrams tablet prescribed to treat insomnia. 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 Zolpidem Tartrate ER 6.25 milligrams tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300-milligrams/2-milliliters to treat chronic obstructive pulmonary disease. 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

You requested Zelnorm 6 milligram tablet prescribed for chronic constipation. 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, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare & Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. The manufacturer, Alfasigma USA, Inc., has sign the agreement and does participate in the Medicare Gap Discount Program.The record shows you purchased Zelnorm 6 milligram tablet. For cash purchases made at in-network pharmacies, the Centers for Medicare & Medicaid Services expects the enrollee to be responsible for the difference between the cash price and the plans negotiated price. In this case, proof of payment in the form of a receipt showing the amount that you paid for the drug 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: Unfavorable

At issue is Eucrisa 2% topical ointment prescribed twice daily for atopic dermatitis. 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. 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 Eucrisa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligram subcutaneous injection prescribed every two weeks for atopic dermatitis. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. 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. 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 Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Vasculera 630 milligram tablets prescribed for chronic venous thrombosis. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Vasculera is not approved by the Food and Drug Administration for safety and effectiveness. Drugs not approved by the Food and Drug Administration are excluded from Part D coverage. Therefore, the Vasculera is not eligible for coverage under Medicare Part D. We have determined that the plan is not required to cover the Vasculera.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lotemax 0.5% Gel to treat cystoid macular edema. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 4 milligram tablet prescribed to treat the enrollees condition. 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.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary 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.A physician reviewed your appeal and determined that the plan is not required to cover Livalo 4 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Humulin R U-500 insulin prescribed 40 unit injections 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Humulin R U-500 insulin to treat your type II diabetes mellitus with hyperglycemia. 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 enrollee has satisfied the plan's coverage criteria. The documentation does not support the enrollee requires at least 200 units per day.A physician reviewed your appeal and determined that the plan is not required to cover Humulin. 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 Dalfampridine Extended Release 10-milligram tablet to treat multiple sclerosis. 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 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 medical records. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Megestrol Suspension 625 milligram/milliliter prescribed for poor appetite, hypomagnesium and chronic kidney disease. 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. Your prescriber indicates Megestrol Suspension is prescribed to treat a poor appetite, hypomagnesemia, and chronic kidney disease. Medications used for anorexia, weight loss, or weight gain are excluded from Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Megestrol Suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Ointment 5% prescribed for pain due to post-herpetic nervous system involvement. 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. Your prescriber indicates that Lidocaine Ointment 5% is prescribed to treat pain due to post-herpetic nervous system involvement. However, Medicare approved compendia does not support this drug for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine Ointment 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80 milligram/milliliter prescribed to treat non-radiographic axial spondyloarthropathy. 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 requested additional information from your prescriber but did not receive a response. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plans prior authorization requirements were not met. A physician reviewed your appeal and determined that the plan is not required to cover Taltz. 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 Mycophenolate Mofetil 500 milligram tablets prescribed for lung transplant rejection prevention. 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.AHFS-DI, a Medicare approved compendia states, 'Mycophenolate mofetil and mycophenolate sodium have been used for the prevention of rejection of lung allografts in patients who have undergone lung transplantation.'  Therefore, the requested drug is being used for a medically accepted indication.  Medicare systems show that your lung transplant was completed while covered under Medicare Part A/B. The drug is not eligible for Part D coverage. It may be covered under Medicare Part B.A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate Mofetil 500 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Botox 100 unit vial prescribed for migraines. The Part D plan did not make a decision.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 record shows Botox is being prescribed to the enrollee for treatment of migraines. 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). The record shows the Botox was given in the physicians office from their supply. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Botox. 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

At issue is Lidocaine and Prilocaine Cream 2.5%. 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 prescriber indicates that Lidocaine and Prilocaine Cream is not being used for topical anesthesia. Medicare approved compendia state that this drug, in this form, is medically indicated only for topical local anesthetic to skin. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine and Prilocaine Cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Phentermine Hydrochloride 375 milligram tablets prescribed to treat obesity..   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.Drugs prescribed to treat weight gain (promote weight loss) 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 a request for a tiering exception for Budesonide 3 milligram delayed release capsules prescribed for colitis. 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. Budesonide is a generic drug on Tier 4 of the plans formulary. There are no generic drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no generic drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Budesonide at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol 180 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We requested additional information and medical records from your prescriber but did not receive a response. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plans prior authorization requirements were not met. A physician reviewed your appeal and determined that the plan is not required to cover Nexletol. 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 Trientine Hydrochloride 250 milligram capsules prescribed as directed for Wilson's disease. 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.Your medical records show your doctor prescribed Trientine Hydrochloride to treat your Wilson's disease. 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 enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Trientine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 25 microgram tables. 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.Synthroid a brand drug on Tier 1 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 Cyclobenzaprine Hydrochloride 10 milligram tablet prescribed three time daily for muscle spasms associated with lower back pain secondary to lumbar spinal stenosis. 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 received the documentation and included it in our review.Your medical records show your doctor prescribed Cyclobenzaprine Hydrochloride to treat muscle spasms associated with lumbar spinal stenosis which is a chronic condition. 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.