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

You requested Tacrolimus 1 milligram prescribed as directed following a lung transplant. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited 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 also researched Medicare systems and reviewed the enrollment data available.The records show your doctor prescribed Tacrolimus 1 milligram after a lung transplant. The record shows that you received a lung transplant on March 16, 2018. According to Medicare enrollment records, you were entitled to Medicare Part A coverage on December 1, 2017. Medicare law excludes coverage for any drug under the Part D program for which payment would be available under Parts A or B. Coverage is available under Medicare Part B for prescription drugs used in immunosuppressive therapy furnished to an enrollee that was covered under Medicare Part A at the time of the transplant. You were covered under Medicare Part A at the time of the transplant. 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 Tacrolimus 1 milligram because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit.You may wish to submit a request for Tacrolimus 1 milligram to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Donepezil HCL 23 milligrams prescribed daily for Alzheimers disease. The Part D plan denied your request for a tiering exception because the drug you requested has been approved as a non-formulary drug.  We received an auto-forwarded 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. The record shows you were prescribed Donepezil HCL. Since the drug isnt on the plans formulary it is not eligible for a tiering exception. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Donezepil HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vraylar 1.5 milligram capsules prescribed every other day for obsessional thoughts and acts, depression, panic disorder and unspecified mood disorder. The Part D plan denied your request because drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Vraylar to treat your obsessional thoughts and acts, depression, panic disorder and unspecified mood disorder. Your prescriber indicated that you were provided with a formal diagnosis of unspecified mood disorder, complex post-traumatic stress disorder and obsessive compulsive disorder. 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 your condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydroxychloroquine 200 milligram tablets prescribed for two tablets daily for systemic involvement of connective tissue and raised antibody titer. The Part D plan denied your request because drug was not eligible for a tiering exception. 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 Hydroxychloroquine to treat your systemic involvement of connective tissue and raised antibody titer. The plan requires that off-label use of a drug is covered if the drug is prescribed for a medically accepted condition as stated in Medicare approved compendia. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug does not qualify for a tiering exception and the plan is not required to cover the drug. A physician reviewed your appeal and determined that the plan is not required to cover Hydroxychloroquine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac 1% gel prescribed four times a day topically for right shoulder pain and chronic low back pain with sciatica. 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. 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. Your medical records show your doctor prescribed Diclofenac to treat your pain. However, the Medicare approved compendia does not support the use of this drug for your condition.
Appeal type: Prescription Drug
Decision: Favorable

You requested Clobazam 10 milligrams prescribed as directed for focal epilepsy. The Part D plan denied your request because it 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 Clobazam 10 milligrams to treat your focal epilepsy. The Medicare approved compendium, DrugDex, has a link to, ' Pharmacological Treatment of Epilepsy: Clinical Practice Guideline.'  In this link there is support for the use of the requested drug to treat focal seizures.  In the Reconsideration appeal the prescriber provided supporting medical records and a prescriber statement dated February 5, 2021, which clarify the diagnosis.The enrollee does not satisfy the Plan's coverage criteria.  However, the prescriber has indicated why all alternatives required by the Plan would likely not be as effective as the requested drug for the enrollee, or would likely cause adverse reaction(s) to the enrollee. Therefore, an exception to the Plans coverage criteria is medically necessary.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitrate 600 plus D plus minerals 600 milligrams/800 milligrams prescribed for unspecified dementia with behavioral disturbance. The Part D plan denied your request because this type of drug is excluded from Part D coverage. 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 determined that the plan is not required to cover Calcitrate because prescription vitamins and mineral products 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

At issue is Acetaminophen-Codeine #4 tablets prescribed for diarrhea related to Crohns disease. The Part D plan denied the request because the provided diagnosis is a non-medically accepted indication. We received a 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. We also researched Medicare regulations and Medicare approved compendia. The prescriber indicates the enrollee has severe diarrhea related to Crohns disease and has exhausted all other medical options and this has been the only effective management strategy. 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 required to cover Acetaminophen-Codeine #4.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doxepin Hydrochloride 10 milligram tablets prescribed to help with sleeping. The Part D plan denied the request and stated the provided diagnosis is a non-medically accepted indication. We received a 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. We also researched Medicare regulations and Medicare approved compendia. The prescriber indicates the enrollee takes this medication at bedtime to help with sleeping. The Medicare approved compendia does support the use of this medication for insomnia. However, the maximum dosage is 6 milligrams per day for this condition. Therefore, Doxepin Hydrochloride at the dosage of 10 milligrams is not medically accepted for the condition reported and is ineligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover Doxepin Hydrochloride 10 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ciprofloxacin HCl 500 milligram tablets prescribed twice daily for a urinary tract infection. The Part D plan did not complete a coverage determination timely. We received an auto-forwarded reconsideration request from the coverage level. 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 medical records or supporting statements to indicate the drug was prescribed for a medically accepted indication. A request for records was submitted to your doctor. The documentation supports the enrollee has purchased the drug and is seeking reimbursement. However, a receipt detailing payment was not received. Additionally, as it cannot be determined that 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 Skyrizi dose kit 150 milligrams as directed to treat psoriasis vulgaris. The case was auto-forwarded by 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.The documentation does not satisfy the plans coverage criteria. The prescriber has not addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the medical records in the case file. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Movantik 12.5 milligrams prescribed as directed. The Part D plan denied your request for a tiering exception because the drug was on the lowest cost share tier allowed by your plan. 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. Movantik 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 Omeprazole 20 milligram capsule administered for unknown diagnosis. The plan provided documentation showing this claim was covered at the time of purchase for the plans cost share amount. The enrollee is requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.The Part D QIC conducted an independent and de novo review of this request for coverage. The QIC reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows the enrollee purchased Omeprazole on September 25, 2020 from a preferred retail pharmacy for an amount that is less than or equal to the required copayment amount. The amount of the copayment was based on the drug's tier and place of purchase. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. The QIC has determined that reimbursement for the copay amount cannot be allowed for the Omeprazole.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligrams prescribed as directed. At initial determination, the diagnosis provided was rheumatoid arthritis (M05.79). At redetermination, the diagnosis of psoriasis was given. The Part D plan denied the request stating that medical records were not provided. 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.At reconsideration a diagnosis was not given. No medical records were provided by the prescriber. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pred Forte 1% Suspension prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other branded drugs on a lower cost-sharing tier. 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.Pred Forte is a brand drug on Tier 3 of the plans formulary. Your doctor did not address why all alternative lower-tier medication on the plans formulary would not work for you. All brand drugs on lower tiers have not been tried. 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 a Trelegy Ellipta 100-62.5-25 micrograms/actuation inhaler prescribed as directed for chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception because there were no brand drugs of the same type on the lower cost sharing tiers. 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. Trelegy 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

You requested Avenova 0.01% solution prescribed daily for blepharitis. The Part D plan denied the request because drug is 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. We determined that the drug is not eligible for Part D coverage. Avenova is an eyelid cleanser that does not require a prescription. Therefore, the drug can be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover Avenova solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tizanidine HCL 4 milligrams prescribed as directed for cramps and spasms. The case was auto-forwarded by the plan. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The record shows that your doctor prescribed Tizanidine HCL to treat your condition. The Medicare approved compendium supports the use of this drug to treat your condition. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Tizanidine HCL because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cholestyramine 4 gram powder packs prescribed as directed for idiopathic bile salt malabsorption resulting in diarrhea. The Part D Plan denied your request for a tiering exception because there were no drugs of the same type on lower tiers that could treat this 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.Cholestyramine powder is a generic drug on Tier 4 of the plans formulary. There are no generic drugs of the same type on the lower tiers of the plans formulary to treat the same condition. 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 Alosetron 0.5 milligram tablet to treat Irritable bowel syndrome in a male. 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 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 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 your condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira 40 milligram/0.4 milliliter pen prescribed for your condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for a lower cost-sharing tier. 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.Humira is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier 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 Radicava 30 milligrams/100 milliliters prescribed intravenously to treat amyotrophic lateral sclerosis. The Part D plan denied the request because drugs that can 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. We also researched Medicare systems and reviewed the enrollment data available.Your doctor prescribed Radicava for treatment of amyotrophic lateral sclerosis. The Medicare approved compendium supports the use of Radicava for your condition. However, based on the information provided, we determined the drug would be eligible for coverage under Part B under Medicare rules. As such, the Medicare Part D benefit is not required to cover this drug. We determined that the plan is not required to cover Radicava. Medicare Part B is responsible for the coverage of this drug.