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

You requested Ticagrelor 90 milligram tablet prescribed for 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 you received Ticagrelor as a self-administered drug while in the hospital. According to your plan's Evidence of Coverage, reimbursement is 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 out-of-network pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, the plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined your copay for Ticagrelor was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dexcom G6 Sensor prescribed for the diagnosis of diabetes mellitus with hyperglycemia. 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 Dexcom G6 Sensor because it is not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Colesevelam HCL tablet 625 milligram prescribed for irritable bowel syndrome with diarrhea associated with bile acid malabsorption. 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 Colesevelam to treat your irritable bowel syndrome with diarrhea associated with bile acid malabsorption. 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 Colesevelam HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin ER 20 milligram tablet prescribed every 12 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. On 6/15/2021 the physician has stated that you have tried Xtampza ER 18 milligram.  On 5/4/20212 the prescriber stated, 'I do not want the patient to switch to Xtampza.ER.'  On 5/7/2021 the prescriber stated that the patient has not tried and failed XtampzaER. 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

You requested Amoxicillin 875 milligram tablet 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 plan provided proof that the drug was covered and you were in the initial coverage phase at the time of purchase. The drug was purchased for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrocodone/APAP 10-325 milligram tablet 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 plan provided proof that the drug was covered and you were in the initial coverage phase at the time of purchase. The drug was purchased for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Penicillin VK 500 milligram tablet 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 plan provided proof that the drug was covered and you were in the initial coverage phase at the time of purchase. The drug was purchased for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked for reimbursement for Buspirone Hydrochloride 7.5 milligram tablet. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. We requested additional information from your prescriber. The prescriber indicated the diagnosis requiring this medication is anxiety and this is a continuation of the drug. However, no medical records were submitted, as requested. Therefore, the documentation is insufficient and Medicare Part D benefit reimbursement requirements were not met.  This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if reimbursement can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tizanidine Hydrochloride 2 milligram capsules prescribed for muscle spasms. 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. Your prescriber indicates you have been treated with this medication for more than 10 years with positive results. Your prescriber also states that they personally noticed a higher risk of respiratory dysfunction when present opioids are mixed with Chlorzoxazone/Orphenadrine. However, 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 Tizanidine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sevelamer Carbonate 800 milligram tablets prescribed as directed for hyperphosphatemia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.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, medical records have not been submitted to 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 Sevelamer Carbonate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rasuvo 17.5 milligram/0.35 milliliter auto injector prescribed for severe rheumatoid arthritis. 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 Rasuvo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prevacid 30 milligram capsules prescribed as directed for gastroesophageal reflux disease without esophagitis. 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. Note that Lansoprazole DR 15 and 30 mg capsules are on the plan's formulary.A physician reviewed your appeal and determined that the plan is not required to cover Prevacid.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of an Albuterol Sulfate HFA 90 microgram per actuation aerosol inhaler, 1 inhaler (8.5 grams) per 30 days.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. During this review, a prescriber statement and supporting medical records were requested from the prescriber. The prescriber responded and submitted the requested documentation.The submitted medical records indicate that the Albuterol Sulfate HFA inhaler has been prescribed for the treatment of chronic obstructive pulmonary disease with asthma, which is a medically accepted indication outlined in the Medicare approved compendia. The prescriber notes that the enrollee has been using an Albuterol Sulfate HFA inhaler since January 1, 2010, to manage her asthma symptoms. The Part D plan has no prior authorization requirements for the coverage of the generic Albuterol Sulfate HFA inhaler, which is what is being requested. Additionally, the amount of medication being requested, 8.5 grams per 30 days, does not exceed the plans quantity limit for this drug of 17 grams per 30 days.To summarize, the documentation supports that the medication is being used for a medically accepted indication, there are no other requirements for coverage of the drug by the plan, and the quantity limit has not been exceeded. Therefore, coverage for the drug can be allowed. A physician reviewed the appeal and determined that the plan is required to cover the Albuterol Sulfate HFA inhaler.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Cialis 2.5 milligram tablet prescribed for benign prostatic hyperplasia. 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. Medical records and provider statement support that enrollee has tried and failed medications from the alpha-blocker class, and from the 5-alpha reductase class, in addition to recent trial and failure of the generic equivalent to treat the diagnosis. A formulary exception can be granted for the requested branded medicationA physician reviewed your appeal and determined that the plan is required to cover Cialis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epinephrine auto inject 0.3 milligram/0.3 milliliter prescribed as needed for anaphylaxis. 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. Epinephrine auto inject 0.3 milligram/0.3 milliliter is a generic drug on Tier 3 of the plans formulary. There are no generic 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 prior authorization request for Skyrizi 150 milligram dose kit prescribed for plaque psoriasis. The Part D plan denied coverage.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. The documentation on hand includes a physician supporting statement. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug. As the drug has not been approved, a quantity limit exception or tiering exception cannot be allowed.A physician reviewed your appeal and determined that the requested biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Pregabalin 75 milligram capsules. 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. The documentation indicates that Pregabalin has been prescribed for the treatment of hereditary and idiopathic neuropathy, unspecified. 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 condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. 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 Vancomycin Hydrochloride 125 milligram capsule prescribed four times per day for clostridium difficile diarrhea. 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.The medical records show the doctor prescribed Vancomycin Hydrochloride to treat the enrollees clostridium difficile diarrhea. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records and lab results show the enrollee has clostridium difficile diarrhea. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Vancomycin Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Armonair Digihaler 55 microgram/actuation aerosol powder prescribed for chronic obstructive pulmonary 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 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 your appeal and determined  that the plan is not required to cover Armonair Digihaler.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil 20 milligram tablets prescribed for digital ischemia. 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 indicates your doctor prescribed Sildenafil for digital ischemia. The Medicare approved compendia do not support the use of the drug at issue for your condition. 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipatropium-Albuterol 0.5-3 milligrams per 3 milliliters unit dose ampule for nebulization prescribed for treat chronic obstructive pulmonary disease. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows Ipatropium-Albuterol is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Ipatropium-Albuterol 0.5-3 milligrams per 3 milliliters unit dose ampule for nebulization. Please submit your request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligram tablets to treat male erectile dysfunction, unspecified. 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 Food and Drug Administration 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 Acitretin 10 milligram capsule prescribed daily for lichen sclerosis et atrophicus. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Acitretin to treat the enrollees lichen sclerosis et atrophicus. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Acitretin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tegretol 200 milligram tablets prescribed three times daily 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.Tegretol is a non-formulary drug. 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 Lidocaine 5% patch prescribed daily for right leg pain. The Part D plan did not make a decision. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Lidocaine 5% patch to treat the enrollees right leg pain. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Lidocaine 5% patch.