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

At issue is a request for coverage of Mycophenolate Mofetil 500 milligram tablets. 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 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 indicates that Mycophenolate Mofetil has been prescribed for the management of chronic, recurrent uveitis. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Nicotine Polacrilex 2 milligram lozenge. 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 reviewed your appeal carefully. We reviewed all documentation available. Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.We determined that the plan is not required to cover Nicotine Polacrilex.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Botox 200 units/milliliter solution prescribed as directed for chronic migraine. 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 medical records show the physician prescribed Botox to treat and prevent your chronic migraine headaches. The Medicare approved compendium supports the use of the requested drug for your condition.The records show that you have experienced an inadequate response to two formulary alternatives. The records further indicate that the enrollee is over 18 years old and is experiencing chronic daily migraines for longer than three months.A physician reviewed your appeal and determined that an exception can be granted to cover the drug that is not on your plans formulary. Therefore, the plan is required to cover Botox.
Appeal type: Prescription Drug
Decision: Unfavorable

Prevymis 480 milligram tablets were prescribed for treatment of cytomegalovirus in a kidney transplant recipient. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.At reconsideration, Prevymis 480 milligrams was prescribed for treatment of cytomegalovirus in a kidney transplant recipient. 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 Prevymis.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Erythromycin 250 milligram tablet for gastroparesis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.The documentation shows your doctor prescribed Erythromycin for your gastroparesis. However, the Medicare approved compendia do not support the use of the requested drug, as prescribed, for the treatment of this condition A physician reviewed your appeal and determined that the plan is not required to cover Erythromycin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ipratropium Bromide 0.2 milligram per milliliter nebulizer solution prescribed for the treatment of chronic obstructive pulmonary disease. The Part D plan denied the request. We received the case to perform an independent and de novo review. 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 indicates that the Ipratropium Bromide is going to be administered via nebulizer. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as a nebulizers, if the equipment is used in the patient's home or in an institution that is used as a home. 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. The prescriber has noted that the enrollee currently resides in a skilled nursing facility. In this situation, a skilled nursing facility is an institution used a home and coverage for a drug used in a nebulizer would be available under Medicare Part B. Coverage under Part D is excluded for any drug for which payment would be available under Part B. We determined that the Medicare Part D plan is not required to cover the Ipratropium Bromide. 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

At issue is Sildenafil 20 milligram tablet to treat erectile dysfunction. The Part D plan denied the request. We received a reconsideration 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not FDA approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcipotriene 0.005% cream to treat actinic keratosis. The Part D plan forwarded 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.A request for information was sent to the prescribing physician; however, no further documentation was received. 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Emgality 120 milligram/1 milliliter auto-injector prescribed for migraine headaches. 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 did not include a supporting statement to indicate that all the formulary alternatives were tried and would be ineffective. A request for a supporting statement was sent to your doctor; however, no documentation was received.A physician reviewed your appeal and determined that the plan is not required to cover Emgality.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Wixela 250-microgram-50-microgram Powder Inhub to treat the enrollee's condition.  The Part D plan denied the request. The requested drug is not on the plans formulary. 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.In the Reconsideration appeal medical records were requested.  No medical records were provided.  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 a request for coverage of Methylphenidate Hydrochloride ER 10 milligram extended release tablets. 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 the case file carefully. We reviewed all documentation submitted. The documentation indicates that Methylphenidate Hydrochloride ER has been prescribed for multiple sclerosis related fatigue. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the Methylphenidate Hydrochloride ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a prior authorization for Zolpidem Tartrate 10 milligram tablets. 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 does not include a supporting statement or medical records to support a prescribed diagnosis. A request for information was sent to the prescribing physician; however, no further documentation was received. As it cannot be determined that the drug was 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 Eszopiclone 3 milligram tablet prescribed to treat 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. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Eszopiclone 3 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vimpat 150-milligram tablet to treat seizures. 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.Relevant medical records were requested. No medical records were provided by the prescriber to support this diagnosis. 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.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Myrbetriq ER 50 milligram tablets prescribed for urinary frequency. 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. It should be noted that the formulary page you submitted to us for review is from 2019 and is not the current formulary for your Part D plan. Myrbetriq ER is a brand drug on Tier 4 of your plans formulary. There are no brand drugs of the same type to treat your condition on the lower cost sharing tiers in the plans current formulary. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Myrbetriq ER at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Hetlioz 20 milligram capsule for non-24-hour sleep-wake disorder. 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 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 did not receive the documentation requested.Your medical records show your doctor prescribed Hetlioz to treat non-24-hour sleep-wake disorder. 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 plan's coverage criteria have been satisfied.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz. 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

You requested Diclofenac Sodium 1.5% topical gel for pain associated with a left distal radial fracture. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. The record shows Diclofenac Sodium 1.5% topical gel was prescribed for treatment of your pain associated with a left distal radial fracture. We asked the prescriber to send us medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.The documentation shows your doctor prescribed Diclofenac Sodium 1.5% topical gel for treatment  pain associated with a left distal radial fracture. 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 Diclofenac Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Estradiol 2 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. 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.The prescriber statement submitted indicates Estradiol was prescribed to treat vulvar vaginal atrophy. However, the medical records provided do not show Estradiol was prescribed for a medically accepted indication supported by the Medicare approved compendia. The prior authorization requirements were not addressed because 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 Estradiol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lunesta 3 milligram tablets prescribed for insomnia. 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 records submitted at the reconsideration level. Lunesta 3 milligram tablets was prescribed to treat insomnia. However, the drug is not on the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary 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.A physician reviewed your appeal and determined that the plan is not required to cover Lunesta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Synthroid 75 microgram tablets prescribed daily for the enrollees condition. 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.Synthroid is a brand drug on Tier 2 of the plans formulary. A supporting statement and medical records were requested from your doctor; however, no further documentation was received. The available documentation on hand does not address why all alternative lower-tier medication.  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

Entresto 97-103 milligram tablet was requested to treat the enrollees condition.  The Part D plan denied your request because medical necessity was not established.  As well, the requested drug has prior authorization criteria.  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.A request was submitted to the prescriber to provide a diagnosis, to clarify the medical history, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dayvigo 5 milligram tablets prescribed for insomnia. The Part D plan denied your request because your diagnoses did not meet the requrements of a 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 your prescriber to send us information regarding 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 other medications on the plan's formulary would not work for you. However, we did not receive the documentation.. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Dayvigo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Perforomist 20 milligram/2 milliliter inhalation medication prescribed for severe persistent asthma. 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.Your doctor submitted a supporting statement that indicates the drug is to be used via a nebulizer in the enrollees home. This is eligible for coverage under Part B. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Perforomist.
Appeal type: Prescription Drug
Decision: Favorable

You requested reimbursement for $387.15 for a Shingrix 50 microgram per 0.5 milliliter (shingles) vaccine received on January 7, 2021. 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 submitted documentation includes the required information including proof of payment for the vaccine that you received on January 7, 2021. Therefore, we have determined that the Part D plan is required to reimburse you for the cost of the Shingrix (shingles) vaccine.
Appeal type: Prescription Drug
Decision: Favorable

You requested Copaxone 40 milligram per milliliter prescribed three times a week for relapsing remitting multiple sclerosis. 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 submitted a supporting statement and medical records. Your medical records show your doctor prescribed Copaxone to treat your relapsing remitting multiple sclerosis. DrugDex, a Medicare approved compendium, supports the use of this drug for your condition.A physician reviewed your appeal and determined that the plan is required to cover Copaxone.