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

At issue is  Rhopressa 0.02% ophthalmic solution prescribed to treat the enrollee's condition.  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

At issue is Advair Diskus 500-50 microgram blister 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. Advair Diskus 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 Anoro Ellipta prescribed for an unknown diagnosis. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the plan reprocessed claims for the Anoro Ellipta and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron Hydrochloride 8-milligram tablet to treat nausea and vomiting due to gastroparesis. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.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 Myrbetriq 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.Myrbetriq is a brand drug on Tier 4 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 Eliquis 5 milligram tablets prescribed to treat atrial fibrillation. 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 Eliquis 5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol 1.25 milligram/3 milliliter inhalation solution 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.The record shows the medication is to be administered through durable medical equipment. This drug is eligible for coverage under Medicare Part B. We determined that the Part D plan is not required to cover Albuterol 1.25 milligram/3 milliliter inhalation solution. You may wish to submit your claim to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix intramuscular vaccine 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. Shingrix is a biological product drug on Tier 4 of the plans formulary. There are no biological product 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 Tacrolimus 1 milligram tablets prescribed twice daily. 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. Tacrolimus is a generic drug on Tier 2 of the plans formulary. There are no generic 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 Aspirin 81 milligram chewable tablet for unknown diagnosis.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to reimburse you for the Aspirin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Fluticasone Prop 50 microgram spray prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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.Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, you did not provide proof of payment for the drug in the form of a receipt. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Metformin HCL 500 milligram tablet prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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.Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, you did not provide proof of payment for the drug in the form of a receipt. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eplerenone 25 milligram tablets prescribed as directed for hypertension. 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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Eplerenone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Divalproex Sodium 500 milligram tablet prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows you requested the plan to reimburse you for the Divalproex Sodium. However, Medicare records indicate that you were not enrolled with the Part D plan for the dates of service requested. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lithium Carbonate 300 milligram tablet prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows you requested the plan to reimburse you for the Lithium Carbonate. However, Medicare records indicate that you were not enrolled with the Part D plan for the dates of service requested. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Olanzpine 10 milligram tablet prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows you requested the plan to reimburse you for the Olanzapine. However, Medicare records indicate that you were not enrolled with the Part D plan for the dates of service requested. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eszopiclone 2 milligram tablet, 180 tablets per 90 days prescribed daily for insomnia. 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 this amount of the medication. We received the documentation and included it in our review.Your medical records show your doctor prescribed Eszopiclone to treat your insomnia. In addition, your medical records show alternative treatments and dosages tried. However, the Medicare approved compendia do not support the use of this specific requested drug dosage for your condition. The maximum clinically indicated dose of the requested drug is 3 milligrams. Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover the Eszopiclone, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrocortisone Acetate 30 milligram suppository prescribed for rectocele. 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. Medicare Part D does not cover drugs that are not FDA approved for both safety and effectiveness. We determined that Hydrocortisone Acetate 30 milligram suppository is not FDA approved for both safety and effectiveness by checking FDA sources. Therefore, the plan is not required to cover Hydrocortisone Acetate 30 milligram suppository. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nexletol 180 milligram tablets prescribed as directed for hyperlipidemia, unspecified. 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 Nexletol to treat your hyperlipidemia, unspecified. 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 Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent patch prescribed as directed for cervicalgia, neck pain. 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 documentation shows your doctor prescribed Lidocaine 5 percent patch to treat your cervicalgia, neck pain. However, the Medicare approved compendia do not support the use of this drug for your condition, as prescribed. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5 percent patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zelnorm 6 milligram tablets prescribed as directed for irritable bowel syndrome with constipation. 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 determined that the plan is not required to cover Zelnorm 6 milligram tablets. Medicare does not allow Part D drug plans to cover drugs produced by a manufacturer that does not participate in the Medicare Gap Discount Program. The Centers for Medicare & Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. Records show that the manufacturer, Alfasigma USA, Inc, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, the Part D plan is not required to cover Zelnorm 6 milligram tablets. 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: Unfavorable

You requested Gammagard 10 gram/100-milliliter solution prescribed as directed for inflammatory polyneuropathy, unspecified, sicca syndrome, unspecified, and rheumatoid arthritis, unspecified. 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 Gammagard to treat your inflammatory polyneuropathy, unspecified, sicca syndrome, unspecified, and rheumatoid arthritis, unspecified. 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 Gammagard.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300-milligrams/2-milliliters Injection to treat atopic dermatitis. 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.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

You requested NP Thyroid 30 milligram tablets prescribed as directed for hypothyroidism. 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 the physician prescribed NP Thyroid to treat hypothyroidism. NP Thyroid has not been approved by the Food and Drug Administration. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.We determined that the plan is not required to cover NP Thyroid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Ointment 5%. At redetermination the diagnosis of pain due to a boil was given. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.At reconsideration the diagnosis of furunculosis was given. The use of the requested drug to treat the provided diagnoses are off-label uses. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. 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

At issue is Zoledronic Acid 5-milligrams/100-milliliters to treat postmenopausal osteoporosis. The Part D plan denied the 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 provided addressed the plans coverage criteria, and those criteria were not satisfied. 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 Methylphenidate Hydrochloride 20 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. Methylphenidate Hydrochloride is a generic drug on Tier 3 of the plans formulary. There are no generic 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 Premarin 0.9 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. Premarin is a brand drug on Tier 4 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.