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

At issue a request for coverage of Free Style Libre 14-day sensors prescribed for the treatment of type 2 diabetes with hyperglycemia. 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. Free Style Libre 14-day sensors are for use with a continuous glucose monitor. A continuous glucose monitor is classified by Medicare as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as continuous glucose monitors. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment. Coverage under Part D is excluded for any item for which payment would be available under Part B. We determined that the Medicare Part D plan is not required to cover the Free Style Libre 14-day sensors. This decision does not address the medical necessity or appropriateness of the item. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brilinta 90 milligram tablet prescribed twice daily. 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. Brilinta 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

You requested Nexletol 180 milligram tablet prescribed daily for mixed hyperlipidemia. 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 Nexletol to treat your mixed hyperlipidemia. 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 Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promacta 75 milligram tablet prescribed for aplastic anemia. 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 plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Your prescriber submitted documents supporting this is an initial start of the medication to treat aplastic anemia. However, the documentation provided does not support you have satisfied the plan's prior authorization requirements. A physician reviewed your appeal and determined that the plan is not required to cover Promacta. 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 a request for coverage of Budesonide 0.5 milligram per 2 milliliter suspension prescribed for the treatment of moderate persistent asthma. 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 indicates that the Budesonide is going to be administered via nebulizer. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as a nebulizers. Payment will also be made under Medicare Part B for the drugs that are put into the nebulizer. Coverage under Part D is excluded for any drug for which payment would be available under Part B. We determined that the Medicare Part D plan is not required to cover the Budesonide. This decision does not address the medical necessity of the requested drug. It only establishes that payment cannot be made under the Medicare Part D prescription benefit. Please submit your request to Medicare Part B, as Medicare Part D and Medicare Part B are two separate entities.
Appeal type: Prescription Drug
Decision: Favorable

You requested Stivarga 40 milligram tablet prescribed 63 tablets for 30 days for metastatic colon cancer. 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 medical records show your doctor prescribed Stivarga to treat your metastatic colon cancer. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided indicated you have satisfied the plan's coverage criteria. The following citation was referenced in the American Hospital Formulary Service Drug Information, a Medicare approved compendium, and supports the use of this drug for your condition: Regorafenib is used for the treatment of metastatic colorectal cancer in patients who have received Fluoropyrimidine-, Oxaliplatin-, and Irinotecan-containing regimens; a vascular endothelial growth factor inhibitor (anti-VEGF therapy); and, in those with tumors bearing the wild-type (nonmutated) KRAS gene, an epidermal growth factor receptor inhibitor (anti-EGFR therapy).A physician reviewed your appeal and determined that the plan is required to cover Stivarga. Stivarga will be used as monotherapy. You have been exposed to 5FU, Oxaliplatin, Irinotecan, Avastin and you are KRAS mutated, so you cannot get anti EGFR therapy. Therefore, the prior authorization requirements have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Zolpidem Tartrate 10 milligram tablet prescribed for 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Zolpidem Tartrate to treat your insomnia. 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 Zolpidem Tartrate. 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 Crestor 20 milligram tablets. 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.Crestor is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lynparza 150 milligram tablet (dosing frequency unknown) prescribed for metastatic bladder cancer. 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 Lynparza to treat your metastatic bladder cancer. However, the Medicare approved compendia do not support the use of this drug for your condition and the article provided is not from a Medicare approved journal.A physician reviewed your appeal and determined that the plan is not required to cover Lynparza.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrocodone Bitartrate-Acetaminophen 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 the plan reprocessed a claim for the Hydrocodone Bitartrate-Acetaminophen and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for your share of any deductible and copay. We have determined that the plan is correct in its calculation of additional copay amounts due to reconciliation of your true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Topiramate 50 milligram tablets prescribed for neuropathy of the foot from Charcot-Marie disease. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not include medical records to support a covered diagnosis. The original diagnosis submitted for review is not supported by the Medicare approved compendia as a medically accepted indication. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 5 milligram tablet. At initial determination and redetermination no diagnoses were provided. 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.At reconsideration level a diagnosis of chronic insomnia was given, with indication of Zolpidem extended release 6.25 milligram being requested. We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation. We did not receive the documentation requested. Specifically, no medical records were provided for review. In this case, we reviewed Zolpidem Tartrate 5 milligram tablet. It could not be determined whether the drug was being prescribed for a medically accepted indication. Therefore, the 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 Zolpidem Tartrate 5 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed daily for pain. The Part D plan denied your request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. We asked your prescriber to send us information regarding your condition. We did not receive the documentation requested. The documentation shows your doctor prescribed Lidocaine 5% patch to treat your pain. However, the Medicare approved compendia do not support the use of this drug for your condition. It is unclear where you are to apply the patch, how long your pain has been going on, and the intensity of the pain.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclogyl 5 milliliter eye-drop solution prescribed for anterior scleritis. 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 Cyclogyl to treat your anterior scleritis. 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 Cyclogyl.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Elmiron 100 milligram 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. 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 Havrix suspension vaccine for hepatitis A prophylaxis. 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 documentation provided includes a request for reimbursement and a receipt showing you paid for the vaccine and its administration. However, the record shows you were administered the vaccine at an out-of-network clinic. Therefore, we determined that the plan is not required to reimburse you for the Havrix vaccine and its administration.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Combivent Respimat 20-100 microgram prescribed for chronic obstructive pulmonary 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 they prescribed Combivent Respimat 20-100 microgram to treat chronic obstructive pulmonary disease. 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. Your prescriber does not state why all 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 Combivent Respimat 20-100 microgram.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Novolog Mix 70-30 vial 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. Novolog Mix is a biological drug on Tier 6 of the plans formulary. There are no biological 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 Contour Next Test Strip 100 per 90 days, diagnosis not provided. 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 Contour Next Test Strip because it is not considered a medical supply directly associated with the injection of insulin. Although, this supply 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 supply. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Wixeta Inhub 250-50 micrograms per dose inhalation aerosol powder prescribed to treat asthma. 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 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.  A physician reviewed your appeal and determined that the plan is not required to cover Wixeta Inhub 250-50 micrograms per dose inhalation aerosol powder.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for cervicalgia and dorsalgia. 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 Lidocaine 5% patch prescribed to treat your cervicalgia and dorsalgia. 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Invokana 100 milligram tablets prescribed as directed for type 2 diabetes. 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 Invokana.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Privigen 10% (45 gram per 450 milliliter) solution for intravenous infusion. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any other information submitted at the reconsideration level. The submitted medical records indicate that the enrollee is receiving Privigen in the management of nonfamilial hypogammaglobulinemia (reduced serum immunoglobulin levels) due to the presence of common variable immunodeficiency. While common variable immunodeficiency is a medically accepted indication for the use of Privigen outlined in the Medicare approved compendia, the administration of Privigen in the treatment of reduced serum immunoglobulin levels due to the presence of common variable immunodeficiency is covered under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law. As such, our decision is that the Part D plan is not required to cover the Privigen. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked for reimbursement for Oxycodone 15 milligram tablet. 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 showing the amount was paid. There is a document labeled as a receipt but only shows amount due.A physician reviewed your appeal and determined that the plan is not required to reimburse the amount of the Oxycodone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Humira (CF) 40 milligram per 0.4 milliliter subcutaneous syringe injection kit prescribed for rheumatoid arthritis. 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. The Part D plan has prior authorization requirements that must be met before coverage of this medication will be approved. 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.