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

At issue is Cosentyx 150 milligrams per milliliter subcutaneous injection prescribed for the treatment of plaque psoriasis. The Part D plan denied coverage because the prior authorization requirements were not met. We received a reconsideration 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. The submitted documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed all of the plans requirements for coverage of this medication. 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 reimbursement for Amitriptyline/Diclofenac/Lidocaine/Metronidazole/Nifedipine 3/3/5/10/2% cream for post-operative rectal pain. The Part D plan did not did not provide a timely redetermination decision. 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 and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The Medicare approved compendia indicates this compound drug includes Amitriptyline Hydrocloride and Nifedipine which are not medically indicated for topical use. The compound also contains Metronidazole and Diclofenac which are not medically indicated for the provided 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 reimbursement of Amitriptyline/Diclofenac/Lidocaine/Metronidazole/Nifedipine 3/3/5/10/2% cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fentanyl 25 micrograms/hour transdermal 72 hour patch to treat lumbar stenosis, left shoulder pain, and right knee degenerative joint 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is reimbursement for Shingrix injection. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. The information provided supports all requirements have been met for reimbursement of a Shingrix injection.A physician reviewed your appeal and determined that the plan is required to reimburse the amount of the Shingrix injection.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Metoprolol tartrate 25 milligram tablets prescribed for an unknown diagnosis. The Part D plan denied your request for additional reimbursement. We received an auto-forwarded reconsideration request from the plan.We received a 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 in the initial coverage stage of the Part D benefit. The plan calculates reimbursement based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The record shows the plan paid its share of the cost for the Metoprolol tartrate and the remaining amount was your copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Brilinta 90 Milligram tablets prescribed for an unknown diagnosis. The Part D plan denied your request for additional reimbursement. We received an auto-forwarded reconsideration request from the plan.We received a 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 in the initial coverage stage of the Part D benefit. The plan calculates reimbursement based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The record shows the plan paid its share of the cost for the Brilinta and the remaining amount was your copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Asmanex 220 microgram/inhaler for a 30 day supply. The Part D plan denied your request for additional reimbursement. We received an auto-forwarded reconsideration request from the plan.We received a 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. You are responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined this drug was paid correctly and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Welchol 625 milligram tablets prescribed for Crohns disease and unspecified diarrhea. The Part D plan denied your request because the drug was not prescribed for 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 submitted documentation indicates your doctor prescribed Welchol for Crohns disease and unspecified diarrhea. 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

At issue is Cyproheptadine Hydrochloride 25 milligrams/5 milliliter syrup to treat loss of appetite. 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 to treat anorexia and/or weight loss, unrelated to AIDS wasting or cachexia due to certain chronic diseases, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a 90-day supply of Alprazolam 1 milligram tablets to be taken once daily for generalized anxiety disorder. The Part D plan denied your request because Alprazolam is limited to a 30-day supply by the plan.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. Alprazolam is listed on the Part D plans formulary with a quantity limit of a recurring 30-day supply. An exception to the quantity limit criteria cannot be granted. A physician reviewed your appeal and determined that the plan is not required to cover a 90-day supply of Alprazolam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise 600 milligrams tablets to treat the diagnosis of complex regional pain syndrome. 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. A request was submitted to the prescriber to provide a prescribers statement and to provide supporting medical records. However, a reply from the prescriber was not received. The documentation is insufficient to support the plan's coverage criteria.Brand name Gralise, is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain 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.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% ointment to treat the diagnosis of complex regional pain syndrome. 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. A request was submitted to the prescriber to provide a prescribers statement, to address the prior authorization criteria, and to provide supporting medical records. However, a reply from the prescriber was not received. The documentation is insufficient to support the plan's coverage criteria.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 prevention 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 a tiering exception request for Eliquis 5 milligram tablets for treatment of 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 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 tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the tiering exception criteria have not been met and the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Asacol HD 800 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for a lower cost-sharing tier. We received 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.Asacol HD is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Urelle 81 milligram tablets prescribed as directed for chronic dysuria. The Part D plan denied your request because Medicare Part D does not cover less than effective Drug Efficacy Study Implementation 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. Urelle is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website. We determined that the plan is not required to cover Urelle. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. 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

At issue is Myfortic 180 milligram tablets prescribed as directed following a kidney transplant. The Part D Plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited 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 other information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The record shows you that your doctor prescribed Myfortic following your kidney transplant. According to Medicare records, you were enrolled in Medicare Part A when your kidney transplant was performed on December 9, 2006. Therefore, Myfortic is covered under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law.As such, our decision is that the Part D plan is not required to cover Myfortic. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 10 milligram capsules prescribed for loss of appetite/anorexia. The Part D plan denied your request because drugs prescribed to treat weight loss do not meet the definition of Part D drugs. 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 Dronabinol because it was prescribed to treat anorexia. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Saxenda 8 microgram/3 milliliter pen prescribed to treat weight gain. The plan denied the request because Medicare excludes Part D coverage of drugs used for the treatment of weight gain or obesity. We received a reconsideration request.We received a 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.The record shows the enrollee was prescribed Saxenda for the treatment of weight gain. We determined the plan is not required to cover Saxenda because it is excluded from coverage under Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cinacalcet hydrochloride 30 milligram tablets prescribed for use with dialysis for end stage renal disease. The Part D plan denied your request because the drug is not eligible for coverage. We received a reconsideration request. We received a 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 cannot be approved for separate payment under Part B or Part D when their use is related to end stage renal disease and dialysis. The record shows the enrollee has end stage renal disease and is on dialysis. Therefore, the Cinacalcet hydrochloride must be billed by the renal dialysis facility. We determined that the plan is not required to cover the Cinacalet hydrochloride. Please submit your request for this drug through your dialysis provider.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 100 milligram tablet to treat chronic headache. 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.Our physician reviewer's opinion is that the plan is not required to cover this drug because the diagnosis in not a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin ER 10 milligram tablets prescribed for the treatment of chronic back pain. The Part D plan denied coverage because the prior authorization requirements were not met. 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. The documentation does not satisfy the plans coverage criteria. The prescriber has addressed the prior authorization criteria, and the responses do not satisfy all of the plans requirements for coverage of this medication. 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 Xolair 150 milligrams/ milliliter-prefilled syringe to treat angioneurotic edema sequela and/or other urticaria. 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 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

You requested Budesonide 0.5 milligram/2 milliliter suspension prescribed for cerebal palsy with chronic respiratory failure. The Part D plan denied your request because drugs that could be covered under Medicare Part B are not eligible to be covered under Medicare Part D. We received a reconsideration 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 Budesonide is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Budesonide. Please consider submitting this 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 Diclofenac sodium 1% topical gel prescribed as directed for osteoarthritis of both knees. The Part D plan denied coverage because the prior authorization criteria were not met. 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 records submitted at the reconsideration level. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We received some of the documentation requested and included it in our review.The prescriber statement shows the physician prescribed Diclofenac sodium 1% topical gel for an enrollee with osteoarthritis in both knees. However, medical records were not submitted for review. There is insufficient documentation to determine if the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac sodium 1% topical gel.