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

At issue is Ipratropium albuterol .5-3(2.5) milligram/3 milliliter solution prescribed for chronic obstructive pulmonary disease. The 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 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 Ipratropium albuterol. 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.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Xifaxan 550 milligrams twice daily to prevent hepatic encephalopathy.   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 satisfies the plans coverage criteria. The diagnosis of hepatic encephalopathy has been established, and lactulose has been used, and is currently in use, but has not controlled symptomatology. 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 Otezla 30 milligram tablet to treat arthropathic psoriasis, other hypertrophic osteoarthropathy of multiple sites, and pain in unspecified joint. 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 medical records show the requested drug is being prescribed to treat the enrollees condition. However, Otezla is not on the plans formulary. 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. Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed the appeal and determined that the formulary exception criteria have not been meet and the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lyrica CR 165 milligram tablets prescribed daily for pain and spasticity from cerebral palsy and spastic quadraparesis. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received an expedited 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. Your medical records show your doctor prescribed Lyrica CR 165 milligram tablets daily to treat your pain and spasticity from cerebral palsy and spastic quadraparesis. 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 Lyrica CR 165 milligram tablets because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ursodiol 500 milligram tablets prescribed twice daily following a liver transplant for other specified diseases of the biliary tract. The Part D plan denied your request for a tiering exception at initial coverage determination because the requested drug was not prescribed for a medically accepted indication. At redetermination, it is indicated that coverage would be provided at the cost sharing level in the 2021 Drug Guide. We received an expedited reconsideration request. We performed and 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 medical records show your doctor prescribed Ursodiol 500 milligram tablets following a liver transplant to treat your other specified diseases of the biliary tract. However, there are no drugs of the same type to treat your condition on a lower tier. No other alternative drugs were mentioned by the prescriber as tried and failed. Therefore it 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 Oxycontin ER 20 milligram tablets to treat chronic pain. 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 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 indicated why the alternative medication on the plans formulary 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 coverage criteria is not supported. Our Physician Reviewers opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Carboplatin prescribed for metastatic, stage 4, non-small cell lung cancer. The Part D plan denied your request. 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 records show you prescribed Carboplatin to treat the enrollees metastatic non-small cell lung cancer. However, the documentation submitted does not include medical records to support previous treatment regimen for stage 3A, biopsy report, and molecular testing.   A physician reviewed your appeal and determined that the plan is not required to cover Carboplatin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Keytruda prescribed for metastatic, stage 4, non-small cell lung cancer. The Part D plan denied your request. 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 records show you prescribed Keytruda to treat the enrollees metastatic non-small cell lung cancer. However, the documentation submitted does not include medical records to support previous treatment regimen for stage 3A, biopsy report, and molecular testing.   A physician reviewed your appeal and determined that the plan is not required to cover Keytruda.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Alimta prescribed for metastatic, stage 4, non-small cell lung cancer. The Part D plan denied your request. 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 records show you prescribed Alimta to treat the enrollees metastatic non-small cell lung cancer. However, the documentation submitted does not include medical records to support previous treatment regimen for stage 3A, biopsy report, and molecular testing.   A physician reviewed your appeal and determined that the plan is not required to cover Alimta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram oral tablet. The Part D plan denied your request for a tiering exception. 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. Eliquis 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 your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Liothyronine/Levothyroxine 15 microgram/50 microgram compound. The Part D plan denied your request because the drugs within the compound were bulk powders that did not meet the definition of a Part D drug. 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 determined that the plan is not required to cover the Liothyronine/Levothyroxine compound. The drugs that make up the compound are bulk powders that do not meet the definition of Part D drugs. 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

At issue is Estradiol 10 microgram vaginal insertion prescribed for desquamative inflammatory vaginitis. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 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 plans formulary would not work for you. However, we did not receive the documentation.The records do not show why the enrollee cannot take all other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Estradiol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rubraca 200 milligrams prescribed for ovarian/peritoneal cancer, not identified as recurrent and without breast cancer gene (BRCA) or germline mutations. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. If prior approval is not obtained, the plan may not cover the drug. 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 Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees diagnosis.  No journal articles are provided. 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 Rubraca. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metaxalone 800 milligram tablets prescribed for chronic pain. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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. Your physician submitted a supporting statement. The supporting statement did not indicate all formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Metaxalone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Memantine ER 21 milligram tablets to treat the enrollees condition. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan.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 asked for the prescribers statement, completion of the prior authorization questionnaire, and documentation to show why the requested drug was needed. However, we did not receive the requested documentation. The documentation is insufficient to support the plan's coverage criteria. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the plans coverage criteria have not been met and the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% patch to treat pain due to a spinal stenosis.  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

You requested off-formulary drug Tizanidine Hydrochloride four milligrams prescribed for Raynauds syndrome and low back pain. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization requirements be met before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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. Your medical records show your doctor prescribed Tizanidine Hydrochloride to treat your condition. 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 Tizanidine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Venclexta 100 milligram tablet prescribed for Myelodysplastic syndrome. The Part D plan denied your request because Venclexta is not approved by the Food and Drug Administration or supported by a Medicare approved drug compendia for your condition. 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 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: Favorable

At issue is reimbursement for Shingrix injection. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. The information provided includes the receipt for the vaccine and the administration date from the provider's office. You meet the medically accepted indications for the vaccine. Therefore, the requested drug is eligible for coverage under Medicare Part D.Our physician reviewers opinion is that the plan is required to reimburse payment of the Shingrix injection.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Aspirin 81 milligrams. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. The drug that is requested, Aspirin, is an over-th- counter item and is non-prescription. Non-prescription drugs are excluded from Medicare Part D drug benefits.Our physician reviewers opinion is that the plan is not required to cover a reimbursement for Aspirin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Gabapentin 300 milligram capsules. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. The information provided does not include any medical records to determine why the drug was required. We are unable to be determined if the drug is medically indicated. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our physician reviewers opinion is that the plan is not required to cover reimbursement of Gabapentin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Meloxicam 7.5 milligram tablets. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. The information provided does not include any medical records to determine why the drug was required. It was unable to be determined if the drug was medically indicated. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our physician reviewers opinion is that the plan is not required to reimburse payment of Meloxicam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Methocarbamol 500 milligram tablets. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. The information provided does not include any medical records to determine why the drug was required. It was unable to be determined if the drug was medically indicated. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our physician reviewers opinion is that the plan is not required to reimburse payment of Methocarbamol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Pantoprazole Sodium 40 milligram tablets. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. The information provided does not include any medical records to determine why the drug was required. It was unable to be determined if the drug was medically indicated. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our physician reviewers opinion is that the plan is not required to reimburse payment of Pantoprazole Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Pregabalin 75 milligram capsules. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. The information provided does not include any medical records to determine why the drug was required. It was unable to be determined if the drug was medically indicated. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our physician reviewers opinion is that the plan is not required to reimburse payment of Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Monurol 3 gram packet prescribed for recurrent urinary tract infections. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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. A request was submitted for medical records and a supporting statement from your prescriber. No records were submitted to support why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Monurol.