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

You requested Nucala 100 milligrams/milliliters for subcutaneous injection prescribed as directed for 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 the prescriber to send us a supporting statement and medical records showing the medical necessity of Nucala. However, we did not receive the documentation requested.The available documentation does not show why the enrollee has been prescribed Nucala. 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 your appeal and determined that the plan is not required to cover Nucala.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Repatha Sureclick pen injector 140 milligrams/milliliter pen injector to treat hyperlipidemia with atherosclerotic heart disease. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation includes clinical notes which satisfied the plan's coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Testosterone Cypionate 200 milligrams/millimeter injection to treat the diagnoses of hypogonadatropic hypogonadism and testosterone deficiency. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Testosterone Cypionate is a generic drug on Tier 3 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 requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Lipitor 40 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because Lipitor is a brand name Tier 4 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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. The plan shows Lipitor is a brand name Tier 4 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ergocalciferol (vitamin D) 1.25 milligram 50,000 unit capsules 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 levelAccording to Medicare rules, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Ergocalciferol. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Doxycycline hyclate compounded ophthalmic solution prescribed as directed. 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 prescribed Doxycycline hyclate compounded ophthalmic solution. The compounded solution contains Doxycycline hyclate 100 milligram powder for injection and sterile water. The National Drug Code provided for the Doxycycline hyclate ingredient in the compound is not a Food and Drug Administration approved National Drug Code. The compounded ophthalmic solution does not contain any ingredients that meet the definition of a Part D drug. We reviewed your appeal and determined that the plan is not required to cover the Doxycycline hyclate compounded ophthalmic solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rituxan 500 milligrams/50 milliliter vial for injection prescribed as directed for lung transplant rejection. 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 Rituxan for the treatment of antibody-mediated lung transplant rejection. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Rituxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig Auto-Injector to treat migraines. The Part D plan denied a request for this drug. We received an expedited reconsideration request.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 physician submitted a supporting statement. The prescriber statement indicates that the enrollee is an adult patient, who has been improving with less headaches. Medical records were requested and were not provided.  The documentation available 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 Aimovig Auto-Injector.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Alosetron HCl 0.5 milligram tablets for irritable bowel syndrome with diarrhea. 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 Alosetron HCl for irritable bowel syndrome with diarrhea in a male patient. The Medicare approved compendia do not support the use of this drug for your condition. 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

You requested Dronabinol 2.5 milligram capsules prescribed for anorexia and severe stage 4 chronic obstructive pulmonary disease. The Part D plan denied your request because the drug requires prior authorization. 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 documentation shows the doctor prescribed Dronabinol to treat anorexia and severe stage 4 chronic obstructive pulmonary disease. The Medicare approved compendia do not support the use of this drug for the enrollees condition. Since the drug was not prescribed for a medically accepted indication, the drug is not covered by Part D. As such, the prior authorization criteria have not been considered for review.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hysingla ER 40 milligram tablets prescribed as directed for severe back pain. We received the case to perform an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The record shows the physician prescribed Hysingla ER for severe back pain. However, the medical records do not show why the enrollee cannot take other drugs on the plans formulary for their condition.A physician reviewed your appeal and determined that the plan is not required to cover Hysingla ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chlorzoxazone 250 milligrams prescribed to treat the enrollees condition. The Part D plan denied your request because the documentation did not support an off-formulary 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.The records do not show why the enrollee cannot take the other drugs on the plans formulary for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Chlorzoxazone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Megestrol 40 milligrams per milliliter to treat abnormal weight loss due to severe depression. 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 use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested First-Omeprazole 2 milligram/milliliter oral powder prescribed for dysphagia. 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 First-Omeprazole. Drugs compounded from bulk powders are not Food and Drug Administration approved and are therefore not covered under Part D. The plan is not required to cover the First-Omeprazole powder at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira 40 milligrams injection pen prescribed for the treatment of sarcoidosis. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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 the enrollees 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 Humira because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira Starter Pack 80 milligram per 0.8 milliliter and 40 milligram per 0.4 milliliter prefilled syringes to treat psoriasis. 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 Horizant ER 600 milligrams tablets to treat postherpetic polyneuropathy. The Part D plan denied your request for a non-formulary exception. We received an expedited reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The prescriber has not indicated why all alternatives which are required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a compounded cream in Lipoderm Base prescribed to treat 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. The plan denied because the requested drug was filled at an out-of-network pharmacy. However, the plan has failed to provide a compelling reason why utilization of an out-of-network pharmacy is prohibited in this case. The requested drug was compounded and unlikely to be available from an in-network pharmacy. This drug is a compounded drug. Therefore, we reviewed each ingredient individually.  The ingredients of the requested drug are: Amitryptyline Hydrochloride Powder, Clonidine Hydrochloride Powder, Ketamine Hydrochloride Powder, Ketoprofen Micronized Powder, Lidocaine Powder, Nifedipine Powder, Propylene Glycol Liquid, and Lipoderm Base.Propylene Glycol Liquid and Lipoderm Base are non-prescription or over-the-counter (OTC) drugs. Medicare Part D does not cover non-prescription drugs. Therefore, the Propylene Glycol Liquid and Lipoderm Base are not eligible for Part D coverage. Amitryptyline Hydrochloride Powder, Clonidine Hydrochloride Powder, Ketamine Hydrochloride Powder, Ketoprofen Micronized Powder, Lidocaine Powder, and Nifedipine Powder are bulk powders. Bulk powders (i.e., Active Pharmaceutical Ingredients for compounding) do not satisfy the definition of a Part D drug and are not covered by Part D. Therefore, none of the ingredients of the requested drug are Part D drugs. Compounded medications that do not contain at least one ingredient that meets the definition of a Part D drug are excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5 milligram tablets prescribed twice 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.Tadalafil is a non-formulary brand drug. 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 Contrave ER 8/90 milligrams to treat the enrollees condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed for the treatment of weight loss are excluded from coverage. Therefore, this drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is the Levemir FlexTouch pen prescribed nightly for type 2 diabetes mellitus with hyperglycemia. 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 records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Levemir FlexTouch pen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dextroamphetamine 20 milligram tablets three times daily to treat attention-deficit hyperactivity disorder. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone Bitartrate/Acetaminophen 7.5-325 milligram tablet to treat chronic pain. 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.A request was submitted to the prescriber to provide a diagnosis, to address the prior approval criteria, and to provide medical records. However, we did not receive the documentation.The plan limits the amount of Hydrocodone Bitartrate/Acetaminophen 7.5-325 milligram tablets provided to a seven day supply for an initial fill. The prescriber has not provided patient specific clinical rationale indicating that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate Solution 2.5 milligram/3 milliliter. The Part D plan did not provide a timely decision. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. We also researched Medicare regulations and Medicare approved compendia. The information is insufficient to determine if the drug is medically indicated for the enrollees condition and if it is considered a Part D eligible drug.  A physician reviewed your appeal and determined that the plan is not required to cover Albuterol Sulfate Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shringrix 50 microgram/0.5 milliliter injection 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 plan submitted documentation that shows you were still in the deductible stage of the Part D benefit when you purchased the Shringrix. Your plans Evidence of Coverage states that you are responsible for the full cost of covered drugs until the deductible amount of $300 is satisfied. We determined this drug was paid correctly and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chlorhexidine gluconate 0.12% mouth rinse. The Part D plan denied the request for reimbursement.We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The record shows the pharmacy submitted a claim for Chlorhexidine gluconate 0.12% mouth rinse with a National Drug Code of a drug that has not been approved by the Food and Drug Administration. Drugs that have not been approved by the Food and Drug Administration do not meet the definition of a Part D Drug and are not eligible for coverage under the Part D Prescription Drug Benefit.We reviewed your appeal and determined that the plan is not required to reimburse payment for the Chlorhexidine gluconate 0.12% mouth rinse.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine 20 microgram per hour patch prescribed for chronic pain syndrome. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. The records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. The prescriber statement does not address all of the alternative drugs listed on the plans formulary. A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 2 milligram sublingual tablets. 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 the doctor prescribed Buprenorphine Hydrochloride sublingual tablets for chronic pain in neck and low back. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s).A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Invokamet 50-1000 milligram tablets prescribed to be taken twice a day for diabetes. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. The drug is not on the plans formulary. There is insufficient documentation submitted to support all alternatives on the plans formulary had been tried.  A physician reviewed your appeal and determined that the plan is not required to cover Invokamet.