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

You requested Butalbital/Aspirin/Caffeine 50 milligrams/325milligrams/40 milligrams capsules prescribed as directed for migraine with aura, intractable, without status migrainosus. 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 also researched Medicare systems and reviewed the enrollment data available. 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 drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Butalbital/Aspirin/Caffeine capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Chlorthalidone 25 milligram tablets 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 record shows you purchased Chlorthalidone from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated 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 pharmacy charged you. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ferosul 325 milligram tablets 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. According to Medicare rules, drugs that fall into the category of over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover or reimburse you for  the Ferosul. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Folic acid 1 milligram tablets 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. According to Medicare rules, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover or reimburse you for the Folic acid. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Paroxetine hydrochloride 20 milligram tablets 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 record shows you purchased Paroxetine hydrochloride from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated 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 pharmacy charged you. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tolterodine tartrate extended release 24 hour 4 milligram tablets 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 record shows you purchased Tolterodine tartrate from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated 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 pharmacy charged you. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Aquaphor 41% ointment prescribed for unknown diagnosis. The Part D plan denied your request.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 record shows Aquaphor was submitted with National Drug Code 72140-0314-07 for payment to your plan. We found that National Drug Code 72140-0314-07 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined that the plan is not required to cover or reimburse you for the Aquaphor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gabapentin 1.8 grams prescribed for unknown diagnosis. The Part D plan denied your request.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 record shows Gabapentin was submitted with National Drug Code 51927-4213-00 for payment to your plan. We found that National Drug Code 51927-4213-00 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined that the plan is not required to cover or reimburse you for the Gabapentin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 1.5 gram ointment prescribed for unknown diagnosis. The Part D plan denied your request.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 record shows Lidocaine was submitted with National Drug Code 38779-0081-08 for payment to your plan. We found that National Drug Code  38779-0081-08 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined that the plan is not required to cover or reimburse you for the Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Oxaprozin 600 milligram tablet twice daily to treat the enrollees condition. The Part D plan did not make a decision.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 asked your prescriber to send us information about 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 similar medications on the lower teirs would not work for you. However, we did not receive the documentation.Oxaprozin 600 milligram tablet is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate 1.25-milligrams/3-milliliters Vial-Nebulizer to treat chronic obstructive pulmonary disease. 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.Base on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.  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 Anoro Ellipta 62.5-25 micrograms to treat chronic obstructive pulmonary disease. The Part D plan denied the request.  The requested drug is not on the plans formulary. 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.The prescriber has provided patient specific clinical rationale. However, the documentation does not address 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

At issue is Aptiom 400 milligram tablet to treat trigeminal neuralgia.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  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. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate motefil 500 milligrams prescribed twice daily for multiple sclerosis. 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. The record shows you were prescribed Mycophenolate motefil for multiple sclerosis. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Mycophenolate motefil because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 10 milligram tablet prescribed as directed for heart failure with reduced ejection fraction. The Part D plan denied the request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes any information submitted at the reconsideration level.The prescriber was asked to provide relevant medical records to support the diagnosis and the appeal.  No medical records were provided.  Therefore, based upon the current record, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Epolamine 1.3 percent patches prescribed as directed for chronic pain and cervicalgia. 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 also researched Medicare systems and reviewed the enrollment data available. 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 drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Diclofenac Epolamine patches.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nurtec 75 milligram tablets to treat chronic migraines. 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.The documentation includes clinical notes which satisfied the plan's coverage criteria.  Medical records from date of service 3/31/2021 were provided which document that the enrollee has tried and failed Imitrex and Maxalt.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hetlioz 20 milligram capsules prescribed for 90 capsules for 90 days to treat circadian rhythm sleep disorder, free running type in an enrollee who is blind. The Part D plan approved the drug with a limit of 30 capsules per 30 days. 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 also researched Medicare regulations and Medicare approved compendia. The plan limits the coverage of this drug to 30 capsules per 30 days. Therefore, a quantity of 90 capsules per 90 days is over the limit allowed.  A physician reviewed your appeal and determined that the plan is not required to cover 90 capsules per 90 days of Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Aranesp 100 microgram/ 0.5 milliliter injections prescribed as directed for anemia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Aranesp.A physician reviewed your appeal and determined that the plan is not required to cover the Aranesp.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate 2.5 milligram/0.5 milliliter solution prescribed daily for asthma. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received a reconsideration 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 record shows Albuterol was prescribed to treat asthma. The requested drug is being used via nebulizer in the enrollees home. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Therefore, coverage under Part D is excluded for any drug for which payment would be available under Part B.We determined that the plan is not required to cover Albuterol Sulfate. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Myrbetriq EQ 25 milligrams tablets prescribed for overactive bladder. The Part D plan denied your request for a tiering exception because Myrbetriq EQ is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. We received a reconsideration 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. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Myrbetriq EQ is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Trospium Chloride Extended Release 60 milligram capsules prescribed to treat an overactive bladder. The Part D plan denied the request for a formulary 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. 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

At issue is TwoCal HN (High Nitrogen) liquid nutrition for the enrollees condition. 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.Drugs prescribed that are available Over the Counter (OTC) are excluded from coverage under Medicare Part D. Therefore, TwoCal HN liquid nutrition is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to cover TwoCal HN liquid nutrition.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Clobazam 10 milligram oral tablet for adjunctive treatment of generalized idiopathic epilepsy not intractable, without status epilepticus.   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.The prescriber sent a letter dated 4/7/2021 clarifying the medical history and diagnosis.  The prescriber states the requested drug is being prescribed for the adjunctive treatment of medically refractory epilepsy, in an enrollee with generalized tonic-clonic seizures, myoclonic seizures and absence seizures.  The enrollee has tried and failed or had adverse effects with Phenobarbital, Depakote, Neurontin, Tegretol, Phenytoin, Mysoline, Topamax and Keppra.  The enrollee is currently on Lamotrigine and Zonisamide.  The documentation does not satisfy the plans coverage criteria.  The plans prior authorization criteria requires an FDA-approved indication. The following citation in Drugdex, a Medicare approved compendium, supports the use of the requested drug for the enrollees condition:  Clobazam is adjunctive treatment of generalized tonic-clonic seizures in children, young adults, and adults if first-line treatment is ineffective or not tolerated [20].  [20].  National Institute for Health and Care Excellence (NICE): Epilepsies: diagnosis and management. National Institute for Health and Care Excellence (NICE). London, United Kingdom. 2016. Available from URL: https://www.nice.... . As accessed 2016-08-25.Therefore, an exception to the plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage