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

You requested Shingrix 50 microgram/0.5 kit  prescribed for shingles vaccination. 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 were administered the Shingrix vaccine at your physicians office. Payment for vaccines including administration fee is required up front when provided at an out of network pharmacy or provider's office. You will be reimbursed the amount you paid less any deductible, copayment or coinsurance and less the amount the physician charges and the plans approved amount. The plan submitted documentation that shows you were in the initial coverage stage when this claim was submitted. The plan processed your claim and your out of network provider was paid minus your cost share amount. Therefore, we determined that the plan is not required to further reimburse you for the vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch to treat neck and shoulder pain. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked your prescriber to send us information regarding your condition. We also asked for a valid prescribers statement, and medical records or other documentation to show why you need this medication. We did not receive the requested documentation.You requested Lidocaine 5% patches. The prescribers statement submitted is invalid, as the physician did not authenticate the diagnosis or need for the requested drug. In addition, there were no medical records submitted supporting your condition. The QIC is unable to determine if your condition is a medically accepted indication to support the use of the requested drug.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylprednisolone Acetate Powder to be used in a compound capsule to treat autoimmune epilepsy. 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 also researched Medicare regulations and Medicare approved compendia. Your physician indicates methylprednisolone powder is used in a compound medication for autoimmune epilepsy. Drugs compounded from bulk powders are not approved by the food and drug administration and are therefore not covered under Part D.A physician reviewed your appeal and determined that the plan is not required to cover Methylprednisolone Acetate Powder.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram/milliliter solution auto injector prescribed as directed for hyperlipidemia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Elllipta 62.5-25 microgram inhaler 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

You requested Calcitriol 0.25 microgram capsules prescribed to treat chronic kidney disease with secondary hyperparathyroidism of renal origin. 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 clinic note of June 11, 2021, also includes a diagnosis of end-stage renal disease. According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. Drugs which are eligible for Part B coverage are excluded from Part D coverage. We determined that the plan is not required to cover the Calcitriol 0.25 microgram capsules. 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 Dupixent 300 milligrams per 2 milliliter injection prescribed every two weeks for chronic rhinosinusitis with nasal polyposis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level.The medical records show the doctor prescribed Dupixent to treat the enrollees chronic rhinosinusitis with nasal polyposis. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollee is currently receiving therapy with an intranasal corticosteroid, is experiencing significant rhinosinusitis symptoms, has received treatment with a systemic corticosteroid, and has had prior surgery for nasal polyps. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Evenity 210 milligram subcutaneous injection prescribed for osteoporosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.)In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Evenity.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Incruse Ellipta 62.5 microgram blister with device 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. Incruse Ellipta 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

At issue is Colesevelam 625 milligram tablet prescribed six tablets once a day for postcholecystectomy syndrome. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Colesevelam to treat the enrollees postcholecystectomy syndrome. 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 Colesevelam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Januvia 50 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. Januvia 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 Cialis 5 milligram prescribed daily for prostate cancer symptoms. 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 Cialis to treat your prostate cancer symptoms. 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 Cialis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alphagan P Solution 0.1%. 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. Alphagan P 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 Methylphenidate 36 milligram ER tablets prescribed for narcolepsy. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates your doctor prescribed Methylphenidate ER for narcolepsy. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Novolog FlexPen 100 units per milliliter (3 milliliters) pen injector prescribed to treat diabetes.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you.A physician reviewed your appeal and determined that the plan is not required to cover Novolog FlexPen 100 units per milliliter (3 milliliters) pen injector.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 150 milligram oral tablet prescribed daily for multiple sclerosis with associated fatigue. 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 Armodafinil to treat your multiple sclerosis related fatigue. 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 Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Horizant 600 milligram ER tablets prescribed for secondary peripheral neuropathy. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates your doctor prescribed Horizant ER for secondary peripheral neuropathy. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Zolpidem Tartrate 10 milligram tablets prescribed for insomnia. 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 Part D 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 are not 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 prescribed Testosterone Cypionate 200 milligram per milliliter solution. 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. 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 Testosterone Cypionate to treat your hypogonadism. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The medical records 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 Testosterone Cypionate. 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 Rayaldee 30 microgram extended-release capsule prescribed daily for stage four chronic kidney disease with secondary hyperparathyroidism. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Rayaldee.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Retacrit 40,000 units per milliliter solution for injection prescribed to treat anemia due to chronic kidney 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, all 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.A physician reviewed your appeal and determined that the plan is not required to cover Retacrit 40,000 units per milliliter solution for injection.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ketoconazole tablet 200 milligram prescribed for hypercalcemia. 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 Ketoconazole to treat your hypercalcemia. 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 Ketoconazole.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine-Prilocaine 2.5/2.5% cream prescribed to treat radiculopathy lumbosacral region. 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. Your physician indicates they prescribed Lidocaine-Prilocaine 2.5/2.5% cream to be used as a topical local anesthetic for pain. However, the Medicare approved compendia do not support the use of this drug for your condition. The cream was not being used as a topical local anesthetic to genital mucous membranes or during a major or minor dermal procedure. Medical records were requested and no medical records were provided.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine-Prilocaine 2.5/2.5% cream.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Polysaccharide Iron 150 milligram capsules. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Polysaccharide Iron because it is an over-the-counter drug. Nonprescription or over-the-counter drugs are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 100 milligram tablets prescribed to treat fatigue secondary to diffuse small fiber neuropathy. 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 Modafinil 100 milligram tablets to treat fatigue secondary to diffuse small fiber neuropathy and Gabapentin. 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 Modafinil 100 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24 milligram-26 milligram tablet prescribed for chronic heart failure. 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. Entresto 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

At issue is Afrezza 12 unit cartridge prescribed for diabetes mellitus. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to Afrezza.