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

At issue is Nurtec ODT 75 milligram tablet, quantity 8 tablets per 30 days prescribed for chronic migraine headaches. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need this medication. We did not receive the documentation requested. The documentation shows your doctor prescribed Nurtec to treat your chronic migraine headaches. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required tocover Nurtec. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix 50 microgram/0.5 milliliter suspension 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 record shows you requested a copay exception for a Shingrix vaccination. The plan paid its share of the cost for the covered drug and you were responsible for the copay. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, there was no proof of payment, such as a receipt to indicate you paid for more than your copay amount. Therefore, we determined no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sucraid 8500 units/milliliter solution prescribed as directed for sucrase-isomaltase deficiency. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Sucraid to treat your sucrase-isomaltase deficiency. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Sucraid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of a Flovent HFA 110 microgram per actuation aerosol inhaler. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. The medical records indicate that the Flovent HFA inhaler has been prescribed for cough and wheezing due to the presence of pneumonia. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the Flovent HFA inhaler.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amitriptyline Hydrochloride 50 milligram tablets prescribed daily for other 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. The documentation shows your doctor prescribed Amitriptyline Hydrochloride to treat your other insomnia. 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 Amitriptyline Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ztlido 1.8 percent topical patch prescribed as directed for other post-herpetic nervous system involvement. 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 all other drugs on the plans formulary, specifically lidocaine, would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Ztlido.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitriol .05 microgram capsule prescribed for end stage renal disease. 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.  According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. Drugs which are eligible for Part B coverage are excluded from Part D coverage. We determined that the plan is not required to cover the Calcitriol. 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

At issue is Corlanor 5 milligram tablet, quantity 60 tablets per 30 days prescribed for heart failure, dilated cardiomyopathy, and left bundle-branch block. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need this medication. We did not receive the documentation requested. The documentation shows your doctor prescribed Corlanor to treat your heart failure, cardiomyopathy, and left bundle-branch block. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Corlanor. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testopel Pellets 75 milligram prescribed for testicular hypofunction. 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, your physician has not indicated why all 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 Testopel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide Suspension. 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 records indicate the enrollee does not reside in a nursing home and is not in Hospice care. The records support that the drug will be used in a nebulizer at home. This drug is not eligible for coverage under Part D drug benefits. However, this drug may be covered under Medicare Part B benefits. We determined that the plan is not required to cover Budesonide Suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methotrexate Sodium 2.5 milligram tablet prescribed six tablets once a week for systemic sclerosis. The Part D plan denied your request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The documentation shows your doctor prescribed Methotrexate Sodium to treat your systemic sclerosis. 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 Methotrexate Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Diclofenac Epolamine 1.3% patches. The Part D plan denied the request because Diclofenac Epolamine was not included in the plans formulary and there was insufficient documentation to determine if a formulary exception could be granted.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.While the documentation initially submitted to the plan indicates that Diclofenac Epolamine patches have been prescribed for acute back pain due to muscle strain, the medical records submitted at reconsideration indicate that the enrollee is being treated for cervicalgia. During this review, a request was submitted to the prescriber to clarify the diagnosis and to address the alternative medications that are included in the plans formulary to treat the enrollees condition. However, the prescriber did not respond to the request. Due to the conflicting information regarding the condition being treated, it cannot be determined if the drug is being prescribed for a medically accepted indication as outlined in the Medicare approved compendia. Therefore, the drug is not eligible for coverage under Medicare Part D. Since the drug in not eligible for coverage under Medicare Part D, a formulary exception is not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover the Diclofenac Epolamine 1.3% patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Nourianz 20 milligram tablets prescribed for Parkinsons disease. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation on hand did not include a physician supporting statement. A request for a supporting statement and medical records was sent to the prescriber; however, no further documentation was received. The documentation on hand does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.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 Synthroid 88 micrograms 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. Synthroid 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 Myrbetriq 50 milligram 24 hour extended-release oral tablets. 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 Myrbetriq ER 25 milligram tablets prescribed three times 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. Myrbetriq ER  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 Eliquis 2.5 milligram tablet prescribed 2 tablets per day. 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. Eliquis 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 Shingrix 50 microgram/0.5 vaccine prescribed for shingles vaccination. 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 received the Shingrix vaccine from your physician. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plans formulary shows the drug is covered as a Tier 3 drug. The documentation submitted does not include a receipt indicating you paid for the vaccine and its administration fee in full. We determined that the plan is not required to reimburse you for their share of the cost for the Shingrix vaccine and administration fee without proof of payment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate 10 milligram tablets prescribed to treat cognitive deficits resulting from a traumatic brain injury.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 Methylphenidate 10 milligram tablets to treat cognitive deficits resulting from a traumatic brain injury. 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 Methylphenidate 10 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dicyclomine Hydrochloride 10 milligram oral capsule prescribed daily for diarrhea associated with Crohns disease. 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 prescriber statement and medical records show Dicyclomine was prescribed to treat diarrhea, Crohns disease, gastroparesis, esophageal reflux disease, and weight loss. However, the Medicare approved compendia do not support the use of this drug for these conditions. As such, 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 Dicyclomine Hydrochloride. The formulary exception was not addressed because the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Otezla 30 milligram tablets prescribed for psoriatic arthritis. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation did not include a supporting statement. A request for additional information was sent to your physician. Your physician did not submit a supporting statement to indicate the formulary alternatives were tried and failed or were contraindicated.A physician reviewed your appeal and determined that the plan is not required to cover Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Botox 100 unit vial prescribed for unknown diagnosis. 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 drug is being supplied by the prescriber and administered to the enrollee in the prescribers office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined that the plan is not required to cover the Botox. However, according to the plan, Botox has been approved under Medicare Part B. Please submit your request to Medicare Part B. 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

At issue is Neupro 2 milligram/24-hour topical patch 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. Neupro 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 Naproxen/Esomeprazole 500/20 milligram tablets prescribed as directed for osteoarthritis of knees, right shoulder, and gastro-esophageal reflux disease. 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. 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. A physician reviewed your appeal and determined that the plan is not required to cover Naproxen/Esomeprazole.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligram tablets prescribed two tablets twice daily for polymyositis. 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 Mycophenolate Mofetil to treat your polymyositis. The use of the requested drug to treat the provided diagnosis is an off-label use.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ozempic pen injector 1 milligram/0.75 milliliters prescribed for metabolic syndrome, abnormal weight gain, bariatric surgery status and personal risk factors. 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 Ozempic to promote weight loss.  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 Ozempic.