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

You requested Acitretin 25 milligrams prescribed 3 days a week for Hidradenitis suppurativa. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization requirements be met before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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 Acitretin to treat your condition. However, the Medicare approved compendia does 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 Acitretin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clobazam 10 milligrams prescribed three tablets (30 milligrams) twice daily for epilepsy. The Part D plan denied your request because the dosing regimen exceeded the recommended dosages. 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 the Clobazam 10 milligrams (60 milligrams each day). Medicare recommended compendia does not support the excess dosage ordered.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nicardipine 20 milligrams capsule prescribed for unstable blood pressure. 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 prescriber has not indicated why all alternatives on the plan's formulary 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

At issue is Buprenorphine HCL 8 milligrams 120 sublingual tablet  every 30 days prescribed for chronic pain syndrome. The Part D plan denied coverage because there was insufficient documentation to support that the prior authorization criteria were met. 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 physician submitted a supporting statement. The prescriber statement indicates the physician had prescribed Buprenorphine to treat chronic pain.However, the documentations available for review 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 Buprenorphine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor five milligram tablet to treat inappropriate sinus tachycardia.  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 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 Repatha 140 milligram/milliliter injection prescribed for hyperlipidemia. 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. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium-Misoprostol 50 milligram-200 microgram tablets prescribed twice daily for osteoarthritis. The Part D plan denied your request for a tiering 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. This includes the case file from the plan and any information submitted at the reconsideration level.Diclofenac Sodium-Misoprostol is a non-formulary drug. Per Medicare rules, a tiering exception cannot be allowed for a drug that is not on the plans formulary. Therefore, this drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required grant the tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 88 microgram tablets prescribed daily for thyroid removal. The Part D plan denied your request for a tiering 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. This includes the case file from the plan and any information submitted at the reconsideration level.Synthroid 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 grant the tiering exception. There are no lower tiered brand drugs of the same type to treat your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cosentyx 150 milligram syringe prescribed daily for hidradenitis suppurativa. The Part D plan denied your request because 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 medical records show Cosentyx was prescribed to treat your hidradenitis suppurativa with associated nodulocystic acne. However, the Medicare approved compendia do not support the use of this drug for this condition. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Cosentyx.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Orthovisc 30-milligrams/milliliter prescribed for right knee pain.   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 furnished Incident To a physicians service are excluded from Medicare Part D coverage.  Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Shingrix 50 mcg/0.5mL for the prevention of shingles.   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.Shingrix 50 mcg/0.5mL is a biologic drug on Tier 3 of the plans formulary. There are no biologic 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. Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lenvima 10 milligram capsules prescribed twice daily. The plan provided documentation showing this claim was covered at the time of purchase and appropriate copays and deductibles were applied. The enrollee is requesting reimbursement for the amount paid at the time of purchase. We received a reconsideration request.We conducted 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. No additional documentation was requested from the enrollee.The record shows the enrollee purchased Lenvima from an outpatient pharmacy for an amount that is less than or equal to the required coinsurance and copayment amounts. 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 deductible, copayments, coverage gap and catastrophic coverage phase. We have determined that reimbursement for your share of the cost cannot be allowed for the Lenvima.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pentasa 500 milligram capsules. The Part D plan auto-forwarded this case. 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 prescriber has not indicated 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 coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Esbriet 267 milligram capsules to treat idiopathic pulmonary fibrosis. 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.  In the Reconsideration appeal the prescriber addressed the prior authorization criteria and provided supporting medical records.  The documentation satisfies the plans 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

You requested levodopa powder 50 milligram tablet prescribed as directed for Parkinsons disease. The Part D plan denied your request to cover the requested compounded medication. 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. This drug is a compounded drug. Therefore, we reviewed each ingredient individually. The ingredients of the requested drug are: Levodopa powder.Levodopa powder is considered a bulk powder. 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 the Lidocaine 5% patch. 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.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.A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Favorable

You requested Omnipod Dash cartridges insulin delivery system prescribed for uncontrolled type 2 diabetes. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an 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. Your physician submitted a statement supporting the medical necessity for the insulin delivery system. The Medicare approved compendium supports the use of the requested drug for your condition. There are no other insulin delivery systems on formulary.A physician reviewed your appeal and determined that the plan is required to cover the Omnipod cartridges.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spravato 56 milligram spray for the diagnosis of major depressive disorder. The Part D plan denied the request. We received an expedited 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 systems and reviewed the enrollment data available.This medication is excluded from Part D and is subject to Part B. It is not eligible to be covered under the Medicare Part D prescription drug benefit. We have determined that the plan is not required to cover Spravato.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dexilant DR 60 milligram capsules prescribed as directed. 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 reviewed your appeal carefully. We reviewed all documentation available. Dexilant DR 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 Linzess 290 microgram capsules prescribed as directed. 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. Linzess 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 Xifaxan 550 milligrams prescribed one table twice a day for status post small bowel transplant. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Xifaxan to treat your condition. However, the Medicare approved compendia does not support the use of this drug for your condition. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathioprine 50 milligrams to treat autoimmune hemolytic anemia. 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. 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 Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Allopurinol 100 milligram tablet. The Part D Plan denied the request because you purchased drugs through the Veterans Administration hospital. 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.Medicare rules state that coordination of benefits between Part D and Veterans Administration is not allowed. The record shows you are eligible to receive Veterans Administration prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered by a Veteran Administration benefit. We determined the Part D plan is not required to reimburse you for any drugs which were already paid for by a Veterans Administration benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bumetanide .5 milligram tablet. The Part D Plan denied the request because you purchased drugs through the Veterans Administration hospital. 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.Medicare rules state that coordination of benefits between Part D and Veterans Administration is not allowed. The record shows you are eligible to receive Veterans Administration prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered by a Veteran Administration benefit. We determined the Part D plan is not required to reimburse you for any drugs which were already paid for by a Veterans Administration benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cholecalcif 25 microgram tablet. The Part D Plan denied the request because you purchased drugs through the Veterans Administration hospital. 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.Medicare rules state that coordination of benefits between Part D and Veterans Administration is not allowed. The record shows you are eligible to receive Veterans Administration prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered by a Veteran Administration benefit. We determined the Part D plan is not required to reimburse you for any drugs which were already paid for by a Veterans Administration benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Empagliflozin 25 milligram tablet. The Part D Plan denied the request because you purchased drugs through the Veterans Administration hospital. 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.Medicare rules state that coordination of benefits between Part D and Veterans Administration is not allowed. The record shows you are eligible to receive Veterans Administration prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered by a Veteran Administration benefit. We determined the Part D plan is not required to reimburse you for any drugs which were already paid for by a Veterans Administration benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Guafenesin 400 milligram tablet. The Part D Plan denied the request because you purchased drugs through the Veterans Administration hospital. 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.Medicare rules state that coordination of benefits between Part D and Veterans Administration is not allowed. The record shows you are eligible to receive Veterans Administration prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered by a Veteran Administration benefit. We determined the Part D plan is not required to reimburse you for any drugs which were already paid for by a Veterans Administration benefit.