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

You requested Amlopidine besylate 5 milligram tablets prescribed for unknown diagnosis. The plan denied your request for additional reimbursement. We received a reconsideration request.We received a 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 plan submitted documentation showing the Amlopidine besylate was covered 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. We reviewed your plans Evidence of Coverage and determined that the plan was correct in its calculation of copay and is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nystatin-triamcinolone acetonide cream prescribed for unknown diagnosis. The plan denied your request for additional reimbursement. We received a reconsideration request.We received a 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 plan submitted documentation showing the Nystatin-triamcinolone acetone was covered 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. We reviewed your plans Evidence of Coverage and determined that the plan was correct in its calculation of copay and is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rosuvastatin calcium 10 milligram tablets prescribed for unknown diagnosis. The plan denied your request for additional reimbursement. We received a reconsideration request.We received a 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 plan submitted documentation showing the Rosuvastatin calcium was covered 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. We reviewed your plans Evidence of Coverage and determined that the plan was correct in its calculation of copay and is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Terbinafine hydrochloride 250 milligram tablets prescribed for unknown diagnosis. The plan denied your request for additional reimbursement. We received a reconsideration request.We received a 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 plan submitted documentation showing the Terbinafine hydrochloride was covered 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. We reviewed your plans Evidence of Coverage and determined that the plan was correct in its calculation of copay and is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Veltassa 8.4 gram packets. 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. 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 Veltassa because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 80 milligrams tablets. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. This drug is at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hyoscyamine ER 0.375 milligram tablets to treat epigastric pain. 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 Shingrix vaccine prescribed for shingles vaccination. The Part D plan denied your request. We received a 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 record shows you received the vaccination at a network pharmacy. The plan submitted documentation that shows coverage was provided for the Shingrix vaccination. According to your plans Evidence of Coverage, your copay amount is $42. The plan calculates reimbursement 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. We determined that the plan is not required to provide additional reimbursement for the Shingrix vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vancomycin hydrochloride 125 milligram tablets prescribed for unknown diagnosis. The Part D plan approved coverage for the drug.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 record shows you received Vancomycin hydrochloride while you were in the hospital. You submitted documentation to the plan that includes a copy of an itemized hospital bill. The documentation provided indicates the plan approved payment for the Vancomycin hyrdochloride. Therefore, we determined that the plan is required to reimburse you. The plan calculates reimbursement based on the total cost of the drug, minus any deductible, and your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the out-of-network pharmacy (i.e., hospital) charged you.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Acetaminophen 325 milligram tablets. The Part D plan did not provide a timely redetermination decision. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. Acetaminophen is an over the counter item and is 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 a reimbursement for Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Mapap (acetaminophen) 500-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 (OTC) 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 Mapap.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Klor-Con 20 milliequivalent tablets. The Part D plan did not provide a timely redetermination decision. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The information provided does not include a receipt of payment made by the enrollee. The requirements have not been met for reimbursement.A physician reviewed your appeal and determined that the plan is not required to reimburse the amount of Klor-Cor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rosuvastatin calcium 10 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 purchased Rosuvastatin calcium from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, 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 Restasis emulsion 0.05% prescribed daily for dry eye syndrome of bilateral lacrimal glands. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Restasis is a brand drug on Tier 3 of the plans formulary. Brand name drugs are eligible for tiering exceptions to the lowest applicable cost-sharing associated with brand name alternatives. There are no brand drugs of the same type on the lower cost sharing tiers to treat the enrollees condition. Therefore, this drug is not eligible for a tiering exception. Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Clorazepate dipotassium 3.75 milligram tablets prescribed to treat the enrollees condition. 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.Clorazepate dipotassium is a generic drug on Tier 3 of the plans formulary. 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. 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 Avycaz 2.5 grams vials to treat infection and inflammatory reaction due to internal left hip prosthesis. 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.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 Nuedexta 20-10-milligram capsule to treat Alzheimers disease with late onset. 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 Trilepta 600 milligrams four times daily to treat seizures. 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.The plan limits the amount of Trilepta provided to a 30-day supply. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levitra 20 milligram tablets to treat erectile dysfunction. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not FDA approved, 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 Testosterone 50 milligram (1%) Gel to treat hypotestosteronism. 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.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 Dronabinol 5 milligram capsule prescribed as directed for anorexia nervosa. 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. The record shows you were prescribed Dronabinol for anorexia nervosa. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Dronabinol because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligrams prescribed as directed for non-24 hour sleep wake disorder. 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records, sleep logs, and actigraphy results. The prescriber was also asked questions to address the plans prior authorization criteria.Your medical records show your doctor prescribed Hetlioz to treat your condition. Your physician sent answers to the prior authorization questions. However, the records provided do not show the coverage criteria has been met.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz as the prior authorization criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Propafenone Hydrochloride 300 milligram tablet prescribed for your paroxysmal atrial fibrillation. The Part D plan denied your request for a tiering exception because the prescriber did not address all alternatives were tried and failed. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Propafenone Hydrochloride is a generic drug on Tier 3 of the plans formulary. Your doctor submitted a supporting statement. The statement said you had been stable on this drug since 2014. However, your doctor did not address why all alternative lower-tier medication on the plans formulary would not work for you. All generic drugs on lower tiers have not been tried. 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 Silenor 6 milligram tablets to treat the enrollees condition. 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.A request was submitted to the prescriber to provide a diagnosis, to address the formulary alternatives and to provide supporting medical records.  A reply from the prescriber was not received.  Therefore, the prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Durezol 0.05% ophthalmic emulsion to treat the diagnoses of herpes simplex with other ophthalmic complications, herpesviral keratitis, and left eye panuveitis. 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.Durezol is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Durezol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 112 microgram tablets prescribed daily for hypothyroidism. 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. Synthroid 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. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armodafinil 250 milligram oral tablet prescribed daily for excessive daytime sleepiness related to medication and hypersomnia, unspecified. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The record indicates Armodafinil was prescribed for excessive daytime sleepiness related to medication and hypersomnia, unspecified. The Medicare approved compendia do not support the use of this drug for either of these conditions. The plan requires a valid diagnosis 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 Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Hydrocortisone Acetate 25 milligram suppository. 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 Hydrocortisone Acetate suppository.