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

At issue is Famotidine 20 milligram tablet prescribed as a self administered drug in an outpatient setting. We requested 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 proof of payment for the drug has been provided by the enrollee. However, the plans claim information indicates the National Drug Code for the requested drug was either not valid or missing. We reviewed the submitted documentation and determined from the Food and Drug Administration records that the National Drug Code, 60687-595-11, is a valid code for Famotidine. Therefore, the plan is required to reimburse the enrollee for the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Metoprolol Tartrate 50 milligram tablet prescribed as a self administered drug in an outpatient setting. We requested the case to perform an independent and de novo review. To make our decision, we reviewed 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 proof of payment for the drug has been provided by the enrollee. However, the plans claim information indicates the National Drug Code for the requested drug was either not valid or missing. We reviewed the submitted documentation and determined from the Food and Drug Administration records that the National Drug Code, 62584-266-11, is a valid code for Metoprolol Tartrate. Therefore, the plan is required to reimburse the enrollee for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Deep Sea Nasal Spray 0.65% prescribed as self administered drug in outpatient stay. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Loratadine 10 milligram tablet prescribed as self administered drug in outpatient stay. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is PEG 3350 17 gram packet prescribed as self administered drug in outpatient stay. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rhopressa 0.02% ophthalmic solution prescribed one drop in each eye at bedtime for Fuchs' eye 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 Rhopressa 0.02% ophthalmic solution to treat the enrollees Fuchs' eye disease. 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 Rhopressa 0.02% ophthalmic solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Cequa 0.09% Ophthalmic Solution to treat an unknown condition. 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.This drug is being 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 request and determined that non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cinacalcet Hydrochloride prescribed for end stage renal 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 record shows Medicare requires Cinacalcet Hydrochloride to be covered by Medicare Part B, when used in end stage renal disease. This drug may be eligible for coverage under Medicare Part B. Please note that Medicare Part D cannot cover this drug, even if the enrollee does not have a Part B plan.We determined that the plan is not required to cover Cinacalet Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prior authorization for Promethazine Hydrochloride prescribed for nausea associated with migraine headaches. 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 Promethazine Hydrochloride to treat your nausea associated with migraine headaches. 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 Promethazine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amphetamine-Dextroamphetamine 15 milligram tablets prescribed to treat the enrollees condition. The Part D plan denied the 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.Amphetamine-Dextroamphetamine 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 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 a request for coverage of Tadalafil 5 milligram tablets prescribed for the treatment of benign prostatic hyperplasia with lower urinary tract symptoms. 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 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 have not been 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

At issue is Nuedexta 20-10 milligram capsules prescribed for pseudobulbar affect. 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. Your medical records show the doctor prescribed Nuedexta to treat the enrollees condition of pseudobulbar affect. The 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 the appeal and determined that the plan is not required to cover this medication. 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 Travoprost 0.004 percent eye drop  prescribed for primary open-angle glaucoma, bilateral, mild stage. 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 the enrollee's prescriber to send us information regarding the enrollee's 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, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed the enrollee's appeal and determined that the plan is not required to cover Travoprost.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium Gel 1% prescribed for chronic pain due to spinal stenosis of the lumbar region with neurogenic claudication. 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. Diclofenac Sodium Gel 1% is prescribed for chronic pain due to spinal stenosis of the lumbar region with neurogenic claudication. 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 Diclofenac Sodium Gel 1%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis 0.05% eye emulsion prescribed 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.Restasis 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 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 Dronabinol 10-milligram capsule to treat nausea. 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 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 Gemtesa 75 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 a request for reimbursement of $39.59 for Ondansetron 8 milligram tablets purchased on July 31, 2021. The Part D plan denied the request for reimbursement. 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 submitted at reconsideration support that Ondansetron was prescribed for nausea and vomiting due to possible gastroenteritis or possible viral infection. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug for the noted conditions. Therefore, the drug has been prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to reimburse the amount paid for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Breo Ellipta 100-25 microgram inhalation prescribed twice daily for chronic obstructive pulmonary disease. The Part D plan denied the 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. Breo Ellipta 100-25 microgram inhalation  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 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 a formulary exception request for Zubsolv 1.4-0.36 milligram sublingual tablets prescribed to treat the enrollee with chronic pain syndrome. 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 Zubsolv 1.4-0.36 milligram sublingual tablets to treat chronic pain syndrome. Upon redetermination, the Part D plan denied the request stating that the plans formulary criteria was not met. 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 Zubsolv 1.4-0.36 milligram sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligram/milliliter prefilled syringe prescribed for pure hypercholesterolemia, unspecified. 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. We requested additional information from the prescriber but did not receive a response. 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 the other alternative on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Sildenafil 50 milligram tablets to be taken three times daily. 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 prescriber statement and medical records submitted at reconsideration indicate that Sildenafil has been prescribed to treat the enrollees World Health Organization (WHO) Group 1 pulmonary arterial hypertension, which is a medically accepted indication for the use of the drug as outlined in the Medicare approved compendia. The plans prior authorization requirement for coverage of the drug is that the enrollee must have a diagnosis of pulmonary arterial hypertension (WHO Group I) confirmed by right heart catheterization. The submitted medical records show that the enrollee had a right heart catheterization on April 26, 2021, which confirmed the diagnosis of pulmonary arterial hypertension (WHO Group I). The plans quantity limit for the drug is 90 tablets per 30 days, which is what has been requested. Therefore, the documentation submitted at reconsideration supports that the Sildenafil is being used for a medically accepted indication, the plans prior authorization requirements have been met, and the quantity requested has not exceeded the plans quantity limit for the drug. As such, coverage for the drug can be allowed. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% gel prescribed two pumps daily for Klinefelter syndrome. The Part D plan denied the 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.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 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 Xarelto 20 milligram tablet. 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. Xarelto 20 milligram tablet is 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 Nuedexta. The case was auto-forwarded by the plan. 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.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.A physician reviewed the request and determined that Specialty tier drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Desvenlafaxine Succinate ER 25 milligram tablet prescribed for schizophrenia. 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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested. The documentation shows Desvenlafaxine Succinate was prescribed to treat schizophrenia. 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 Desvenlafaxine Succinate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium-Albuterol 0.5-3 milligram/milliliter ampule prescribed for the treatment of chronic obstructive pulmonary disease. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the Ipratropium-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 the requested drug. Please consider submitting this 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.