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

At issue coverage for Imatinib Mesylate 400 milligram tablets prescribed for the treatment of chronic myelogenous leukemia. 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. During this review, a request was sent to the prescriber to address the plans prior authorization criteria for this medication. The prescriber did not respond to the request.The submitted 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 validated 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 VictozaPen Injector 0.6 milligram/0.1 milliliter prescribed to treat type 2 diabetes mellitus with diabetic polyneuropathy. 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.Your prescriber does not indicate you have tried Byetta, Bydureon, or Trulicity. 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 Victoza. 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 ProAir HFA Aerosol Inhaler prescribed for 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. 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 all other drugs on the plans formulary would not work for you. There is no supporting evidence that all the plans formulary, alternative drugs, have been tried.A physician reviewed your appeal and determined that the plan is not required to cover ProAir HFA Aerosol Inhaler.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablet prescribed three times daily for 14 days. 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 included on Tier 5 of the plans formulary. This Tier is identified as a Specialty Tier. The plan is not required to grant a tier exception for drugs available on their Specialty Tier. Therefore, a tier exception cannot be considered.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 Gammaplex 10% vial prescribed for autoimmune cerebellar ataxia. 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. Your prescriber indicates that Gammaplex 10% is prescribed for autoimmune cerebellar ataxia. 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 Gammaplex 10%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ibrance 125 milligram capsule to treat metastatic, hormone receptor positive, HER-2 positive breast cancer in combination with Letrozole. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Idhifa 100 milligram tablet prescribed for IDH2-mutated chronic myelomonocytic leukemia type 2. 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 Idhifa for IDH2-mutated chronic myelomonocytic leukemia type 2. 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 Idhifa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrocortisone Acetate 25 milligram suppository for hemorrhoids. The Part D Plan denied. 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 the Hydrocortisone Acetate is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover Hydrocortisone Acetate. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Promacta 25 milligram oral tablet. 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 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 received the documentation and included it in our review.Your medical records show your doctor prescribed Promacta to treat your thrombocytopenia associated with chronic hepatitis C. 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 Promacta. The prescriber statement and medical records do not support the enrollee is receiving interferon-based therapy. 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 Metformin Hydrochloride 500 milligram tablets, extended release, 150 tablets for 30 days to treat Type 2 diabetes. The Part D plan denied the request.  We performed an independent and de novo review. We reviewed all documentation submitted. 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, in this quantity. We did not receive the documentation requested.The plan limits the amount of Metformin Hydrochloride 500 milligrams tablets, extended release, to 120 tablets every 30 days. We did not receive medical records or a prescriber statement to support the excess quantity requested. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Atorvastatin 10 milligram prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The record shows you purchased medication from a pharmacy on February 7, 2021. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The documentation submitted includes a receipt showing you paid for medications. However, we cannot determine what those medications were. Therefore, the plan is not required to reimburse you for the Atorvastatin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lantus Solostar 100 IU/milliliter injection prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The record shows you purchased medication from a pharmacy on February 7, 2021. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The documentation submitted includes a receipt showing you paid for medications. However, we cannot determine what those medications were. Therefore, the plan is not required to reimburse you for the Lantus Solostar.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested pen needles 32 gauge/4 milliliter prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The record shows you purchased medication from a pharmacy on February 7, 2021. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The documentation submitted includes a receipt showing you paid for medications. However, we cannot determine what those medications were. Therefore, the plan is not required to reimburse you for the pen needles.
Appeal type: Prescription Drug
Decision: Favorable

You requested reimbursement for Hydrocodone-Acetaminophen 10-325 milligram tablets purchased on August 26, 2020, for the amount of $57.98, prescribed for complex regional pain syndrome type 1. 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 record shows that you filled prescriptions for diazepam, lorazepam and hydrocodone-acetaminophen within the same time frame. During this review, a statement and supporting medical records were requested from your healthcare provider acknowledging that the combination of hydrocodone-acetaminophen, diazepam and lorazepam was intended and medically necessary. Your healthcare provider responded with medical records and a statement noting that you are using Hydrocodone-Acetaminophen 10-325 milligram tablets to treat severe nerve pain in the left fingers, which began after cervical fusion surgery. Your provider notes in the statement that you are claustrophobic and the prescription for diazepam was so that you could take the medication prior to a magnetic resonance imaging study; however, that prescription was changed to lorazepam instead. Your healthcare provider goes on to state that the prescriptions for diazepam and lorazepam were one-time prescriptions and that this does not represent regular concomitant use of benzodiazepines and opioid therapy. Therefore, the required statement from you healthcare provider was received and the record includes the required documentation to receive reimbursement for the Hydrocodone-Acetaminophen. We have determined that the plan is required to reimburse the Hydrocodone-Acetaminophen 10-325 milligram tablets purchased on August 26, 2020, for the amount of $57.98.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Combigan 0.2-0.5% ophthalmic solution prescribed twice daily for ocular hypertension. 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.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 records show that the formulary alternative Dorzolamide Hydrochloride-Timolol Maleate was prescribed after the purchase of Combigan and was not 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 reimburse for Combigan 0.2-0.5% ophthalmic solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methadone 80 milligrams for the treatment of opiod dependence provided at a clinic. 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.Medicare Part D does not cover Methadone when not dispensed upon a prescription at a retail pharmacy. The record shows that Methadone will be obtained from a treatment center and it was not dispensed upon a prescription at a retail pharmacy. Therefore, Methadone is not eligible for Part D coverage.We determined that the plan is not required to reimburse you for the Methadone. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement of $753.76 for Xarelto 20 milligram tablets purchased on January 5, 2021. 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 record shows that the amount that you paid for this medication was either a deductible, copay, or coinsurance depending upon your plan benefit and is not eligible for reimbursement. We reviewed your appeal and determined that the plan is not required to reimburse the Xarelto purchased on January 5, 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked for reimbursement for a Shingles vaccine. 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 information provided supports all requirements have been met for reimbursement of a Shingles injection. A receipt has been submitted for the amount of $365.00. A physician reviewed your appeal and determined that the plan is required to reimburse the amount of the Shingles injection.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for the Hepatitis B vaccine Engerix 20 micrograms/milliliter injection. The Part D plan denied the requestWe 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. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules. Therefore, the drug cannot be considered for payment under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Butalbital-Acetylsalicylic acid (ASA)-Caffeine capsules prescribed to treat headaches. The Part D plan denied your request stating that the provided diagnosis is a non-medically accepted indication.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 this medication was needed. We did not receive the requested documentation. The documentation shows your doctor prescribed Butalbital-ASA-Caffeine capsules to treat headaches. Butalbital-ASA-Caffeine is not on the plans formulary. In addition, there was no supporting medical records clarifying the requested drug strength and the type of headache the enrollee was experiencing. 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 Butalbital-ASA-Caffeine capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 500 milligram tablet prescribed three times daily for small intestinal bacterial overgrowth. 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 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 received the documentation and included it in our review.At reconsideration a diagnosis of irritable bowel syndrome with diarrhea was given. However, the medical records provided by the prescriber do not support this diagnosis. The doctor prescribed Xifaxan to treat your small intestinal bacterial overgrowth. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis 0.05% droperette prescribed for dry eye. 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. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zolpidem Tartrate 10 milligram tablet, a quantity of 30 tablets per 30 days prescribed daily for sleep apnea. 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 Zolpidem Tartrate to treat your sleep apnea. 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 Zolpidem Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Aromasin 25 milligram tablets. 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.Aromasin is not included in the plans formulary. The generic version of Aromasin, which is Exemestane, is included in the plans formulary. Your doctor has stated that the Exemestane 25 milligram tablets would be just as effective as the previously ordered Aromasin. Therefore, please work with your doctor to obtain a prescription for Exemestane 25 milligram tablets, as the documentation does not support a formulary exception for the Aromasin. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Docusate Sodium 250 milligram tablet 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.According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to reimburse you for the Docusate Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Goodsense Pain Relief Extra Strength 500 milligram tablets 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.According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to reimburse you for the Goodsense Pain Relief.