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

At issue is Losartan Potassium 100 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. Your plans Evidence of Coverage states that you are 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 Mag-Al Plus suspension 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 Oxycodone 5 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 Timolol Maleate 0.5% 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 Vitamin C 500 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request for reimbursement.   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 Tirosint 100 microgram capsules prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Tirosint is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Tresiba Flextouch 100 units/milliliter to treat Type 2 diabetes mellitus. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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.Tresiba Flextouch is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xcopri 12.5-25 milligrams titration pack tablets. The Part D plan denied the appeal request for a tiering exception.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.Xcopri 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 100 milligram tablets prescribed for erectile dysfunction. 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.We determined that the plan is not required to cover Sildenafil because it was prescribed for erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee 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 Latuda 40 milligram tablets prescribed for post-traumatic stress disorder. 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 submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 620-micrograms/2.48-milliliters Injection to treat osteoporosis in a postmenopausal enrollee who is at at high risk for fracture. The Part D plan denied the request. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 for you.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 Saxenda 18 milligrams per 3 milliliter pen injector prescribed for morbid obesity. 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 Saxenda because it was used to treat obesity. Drugs to treat weight gain (promote weight loss) are excluded from coverage. The enrollees 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 Stivarga 40-milligram tablet to treat recurrent metastatic colorectal cancer. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 provided addressed the plans coverage criteria, and those criteria were not satisfied. 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 Cequa 0.09% solution prescribed to instill one drop in both eyes twice daily to treat the enrollees condition. The Part D plan denied the appeal request for a tiering exception.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.Cequa 0.09% ophthalmic solution 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metaxalone 800 milligram tablet prescribed 0.5 to one tablet at bedtime as needed for muscle spasms due to chronic low back pain and degenerative disc disease. 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 Metaxalone to treat the enrollees muscle spasms due to chronic conditions. However, the Medicare approved compendia do not support the use of this drug for this chronic condition.A physician reviewed the appeal and determined that the plan is not required to cover Metaxalone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Cosentyx Sensoready 150 milligram/milliliter solution prescribed for plaque psoriasis with psoriatic arthritis. 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 submitted documentation did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover the requested biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Actemra Solution prefilled syringe 162 milligram/0.9 milliliter prescribed for acute graft versus host disease and kidney transplant rejection. 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. Actemra Solution is prescribed for acute graft versus host disease and kidney transplant rejection. 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 Actemra Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prevymis 480 milligram tablet prescribed daily for lung transplant status and cytomegalovirus prophylaxis. 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 Prevymis for the enrollees lung transplant status and cytomegalovirus prophylaxis. However, the Medicare approved compendia do not support the use of this drug for these conditions.A physician reviewed the appeal and determined that the plan is not required to cover Prevymis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550-milligram tablets prescribed for clostridium dificile colitis. 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 submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Hydromorphone Hydrochloride ER 12 milligram tablet prescribed daily for back and neck pain. 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 medical records show the physician prescribed Hydromorphone Hydrochloride ER 12 milligram tablet to treat the enrollees back and neck pain. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of the requested drug for the enrollees conditions: Extended-release Hydromorphone is indicated for pain management in opioid-tolerant patients with pain severe enough to necessitate around-the-clock, long-term treatment for whom alternative options are not adequate.The records show that the enrollee cannot take at least two drugs on the plans formulary for these conditions as required by the plan. Specifically, Methadone gave the enrollee a headache and made sick at stomach. Morphine ER was trialed and discontinued due to side effects of excessive grogginess, lethargy, and sweats. A physician reviewed the appeal and determined that an exception can be granted to cover the drug that is not on the plans formulary. Therefore, the plan is required to cover Hydromorphone Hydrochloride ER 12 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 0.25 milligram pen injector prescribed for secondary prevention of a cardiovascular event. We received the case to perform an independent and de novo review. To make our decision, we read all documentation submitted. This includes any information submitted at the reconsideration level. Ozempic 0.25 milligram pen injector is prescribed for secondary prevention of a cardiovascular event. 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 Ozempic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec 75 milligram oral disintegrating tablets prescribed to treat the enrollees unknown condition. 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 records submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. Specifically, we asked for medical records or other documentation (e.g., the diagnosis related to the requested drug) to show why the enrollee needs this medication. We did not receive the requested documentation.The appeal request is for Nurtec 75 milligram oral disintegrating tablets. Upon redetermination, the Part D plan denied the request stating that the plans prior authorization criteria was not met. However, no medical records have been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.A physician reviewed the appeal and determined that the plan is not required to cover Nurtec 75 milligram oral disintegrating tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Albuterol Sulfate 2.5-milligrams/3 milliliter nebulizer solution prescribed for asthma. 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 drug at issue is for use in a nebulizer in the enrollees home. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee 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 Megestrol Acetate 400-milligram/10 milliliter oral suspension prescribed for weight loss. 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.We determined that the plan is not required to cover Megestrol Acetate because it was prescribed for weight loss. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee 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: Favorable

At issue is a prior authorization request for Humira 40 milligram/0.4 milliliter pen injector prescribed for rheumatoid arthritis. 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. The submitted documentation indicates the prescriber ordered the requested biologic for the enrollees noted condition. Furthermore, the submitted documentation indicates that the enrollee satisfies the plan's prior authorization coverage criteria. The prescriber submitted a statement and medical records to support the enrollee has a diagnosis of rheumatoid arthritis, and has had an intolerance to two separate biologic disease modifying anti-rheumatic drugs, Hydroxychloroquine and Sulfasalazine.A physician reviewed the appeal and determined that the requested biologic is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin 20 milligram extended release tablet prescribed for chronic pain. 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 records indicate that Oxycontin 20 milligram extended release tablet is prescribed for chronic pain. The documentation also states that the enrollee had tried and failed Ibuprofen and Norco. However, this drug is not on the plans formulary. 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 prescriber does not indicate why all the other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Oxycontin 20 milligram extended release tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate tablet prescribed for unspecified sleep disorder. 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 Zolpidem Tartrate to treat the enrollees diagnosis of unspecified sleep disorder. 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 Zolpidem Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 4 milligram oral dispersible tablets prescribed to take 1 tablet 3 times daily, as needed, to treat unspecified nausea and vomiting. 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 Ondansetron 4 milligram oral dispersible tablets to treat unspecified nausea and vomiting. The doctor also notes that the cause of the nausea and vomiting was due to enrollee feeling ill. 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 Ondansetron 4 milligram oral dispersible tablets.