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

You requested Less drops (Pred-GATI-BROM) compounded eye drops 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.The record shows you received the drugs from your physician's office. However, the documentation submitted does not include proof of payment  for the Less Drops (Pred-GATI-BROM) compounded eye drops. The plan calculates reimbursement 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 out-of-network (physician's office) charged you. We determined that the plan is not required to reimburse you without proof of payment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trintellix 10 milligram tablets prescribed for the enrollees condition. 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.Trintellix 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

At issue is Febuxostat 40 milligram tablets prescribed to treat gout and right foot pain. 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 medical records show your doctor prescribed Febuxostat 40 milligram tablets to treat your condition. 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 Febuxostat 40 milligram tablets. The plans prior authorization requirements have not been satisfied. 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 Belbuca 750 microgram sublingual film prescribed every twelve hours for chronic pain. 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 documentation does 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 Belbuca.
Appeal type: Prescription Drug
Decision: Favorable

You requested Ondansetron 8 milligram oral disintegrating tablets. 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.The submitted diagnosis is nausea and vomiting in an enrollee with multiple sclerosis. A positive citation in MicroMedex, a Medicare approved compendium, supports the use of the requested drug for the condition indicated:  Ondansetron provided significant symptomatic relief and improved quality of life in 2 multiple sclerosis cases. Therefore, it is considered a medically accepted indication.This generic drug is on the plans formulary without prior authorization criteria pertinent to this case.A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Golytely Packet powder for solution prescribed 4,000 packets per day for excessive sweating. 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 prescriber and the documentation state the doctor prescribed Glycopyrrolate and not Golytely packets to treat the enrollees excessive sweating. However, the plan performed a redetermination only for the drug Golytely. The prescriber will need to submit an appeal to the plan before we can review the drug Glycopyrrolate. The Medicare approved compendia do not support the use of Golytely for this condition. In addition, the prescriber has not indicated that the plans quantity limit would likely be ineffective in treating the condition or would be likely to cause harm.A physician reviewed your appeal and determined that the plan is not required to cover Golytely Packet powder for solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick solution auto-injector 140 milligrams /milliliter prescribed for hyperlipidemia and coronary artery 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. The doctors statement and medical records show Repatha was prescribed for hyperlipidemia and coronary artery 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. 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 Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitriol 0.5 microgram capsules prescribed for secondary hyperparathyroidism. 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.Your doctor submitted a supporting statement that indicates you are on dialysis. Medicare says certain drugs for dialysis patients are covered under the 'bundled' payment to your dialysis facility. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Calcitriol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Arikayce 590 milligram per 8.4 milliliter suspension for oral inhalation. 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.The documentation indicates that Arikayce via oral inhalation has been prescribed for the treatment of bronchiectasis and chronic obstructive pulmonary disease with persistent pseudomonas infection. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover Arikayce.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doxepin Hydrochloride 6-milligram tablet to treat pruritus, unspecified. 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 a tiering exception request for Linzess 72 microgram capsules prescribed for the enrollees condition. 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.Linzess 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

At issue is Promethazine Hydrochloride 25 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 from your prescriber to verify a diagnosis 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 Promethazine Hydrochloride. 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 Zolpidem Tartrate 10 milligram tablets to treat psychophysiologic insomnia. 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 the provided 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

You requested Ciclopirox treatment kit 8% prescribed for toenail fungus. 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 and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the list, the manufacturer, Acella Pharmaceuticals, Inc., did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Ciclopirox treatment kit. 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 initial determination, Horizant ER 600 milligram tablets were prescribed twice daily for radiculopathy, other intervertebral disc degeneration lumbar region, spinal stenosis lumbosacral region, and myalgia, unspecified site. 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 records submitted at the reconsideration level. At redetermination and reconsideration, a diagnosis of restless leg syndrome was provided. No medical records were provided to substantiate the change in diagnosis. We received a prescriber statement and included it in our review. However, we did not receive medical records to support this statement. In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, medical records are required.A physician reviewed your appeal and determined that the plan is not required to cover Horizant ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Febuxostat 40 milligram tablets 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 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

At issue is Exemestane 25 milligram tablets 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. We asked the prescriber to send us information about the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why similar medications on the lower tiers would not work for the enrollee. However, we did not receive the documentation.Exemestane is a generic drug on Tier 4 of the plans formulary. The available medical records do not support that all drugs available on lower tiers to treat the enrollees condition have been tried or deemed contraindicated. Therefore, this drug is not eligible for a tiering exception.A physician reviewed 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 Tadalafil 20-milligram tablet to treat enlarged prostate with lower urinary tract symptoms. 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.At reconsideration the diagnoses of testicular hypofunction, benign prostatic hyperplasia, and hypertension. No medical records were provided by the prescriber to support these diagnoses. 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.A physician reviewed the appeal and determined that the requested drug is excluded from Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Afrezza 4-8-12 units/inhalation titration pack prescribed for type II 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. 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 adequately 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 Afrezza 4-8-12 units/inhalation titration pack.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Synthroid 112 microgram tablets prescribed for hypothyroidism. 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. Synthroid is a brand drug on Tier 3 of the plans formulary. The prescriber has not addressed why all of the brand drugs of the same type on the lower tiers of the plans formulary to treat the noted condition have been tried and failed, or are contraindicated. A physician reviewed the appeal and determined that the plan is not required to cover Synthroid at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Zolpidem Tartrate 10 milligram tablets prescribed for insomnia. 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 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 the provided 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

You requested Perforomist 20 micrograms/milliliter solution prescribed for chronic obstructive pulmonary 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 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 Perforomist was prescribed for chronic obstructive pulmonary disease. However, this drug may be eligible for coverage under Medicare Part B. Medicare Part B local policy states that a small volume nebulizer, related compressor and Federal Drug Administration approved inhalation solutions are covered when medically necessary for the management of obstructive pulmonary disease.We determined that the plan is not required to cover Perforomist.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Esomeprazole Magnesium DR 20 milligram capsule 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. Esomeprazole Magnesium DR is a generic drug on Tier 3 of the plans formulary. Your doctor submitted a statement. However, it did not address why the all drugs available on the lower tiers of your plans formulary would not work for your condition. 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: Partially Favorable

At issue is Vraylar 1.5 milligram capsule (90 capsules) prescribed once a day for bipolar disorder. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your medical records show your doctor prescribed Vraylar to treat your bipolar disorder. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided supports the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Vraylar. Your physician states you have tried at least two of the alternative drugs as required by the prior authorization. Therefore, an exception to the plans prior authorization requirements can be granted at this time. However, a quantity limit exception cannot be made. Specialty drugs are limited to a 30 day supply (30 capsules in this case).
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxaprozin 600 milligram tablet prescribed for your condition. The Part D plan denied your request because the requested drug is not on the plan's formulary. 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 did not receive the documentation requested. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. 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 Oxaprozin.