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

At issue is Repatha Sureclick 140 milligram/milliliter auto-injector prescribed for hypercholesterolemia. The Part D plan denied your request for a tiering 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. Repatha Sureclick is a brand drug that is not on the plans formulary. 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 to grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Thalomid 200 milligram capsules. 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. The submitted documentation does not include a supporting statement, medical records, or evidence of a prescribed diagnosis. A request for information was sent to your doctor; however, no documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed and a quantity limit exception 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 Mekinist 2 milligram tablets prescribed in combination with Plaquenil for stage IV pancreatic cancer. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.   The records show your physician prescribed Mekinist 2 milligram tablets in combination with Plaquenil to treat your stage IV pancreatic cancer. However, the Medicare approved compendia and Medicare approved journals do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Mekinist 2 milligram tablets.
Appeal type: Prescription Drug
Decision: Favorable

You requested reimbursement for Enoxaparin 60 milligram/0.6 milliliter syringe with a quantity of 60 per 30 days prescribed for bilateral peroneal artery occlusion and bilateral lower extremity deep vein thrombosis. The Part D plan did not provide a timely decision. 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 also researched Medicare regulations and Medicare approved compendia. You submitted a receipt that shows Enoxaparin 60 milligram/0.6 milliliter syringe with a quantity of 30 per 25 days was purchased on July 15, 2019, for the amount of $2799.99. The amount of drug received and that you are asking to be reimbursed for is within the quantity limits. The diagnoses are supported as medically accepted indications in the Medicare compendia.A physician reviewed your appeal and determined that the plan is required to reimburse the amount of Enoxaparin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Naproxen 500 milligram tablets 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 you purchased Naproxen from a network pharmacy on November 25, 2020 and December 14, 2020. The fill date of November 25, 2020 was not submitted to your Part D plan and you paid full price for the drug. However, the December 14, 2020 was submitted and the plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined that the copay was calculated correctly for the Naproxen and no further reimbursement is required by the plan for the December 14, 2020 fill date. The plans Evidence of Coverage indicates two refills within a 30 day period exceeds the coverage limit. Therefore, the Part D plan is not required to cover the November 25, 2020 fill date.
Appeal type: Prescription Drug
Decision: Favorable

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 on December 5, 2020. 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 includes a receipt indicating you paid for the administration fee in full. We determined that the plan is required to reimburse you for their share of the cost for the Shingrix vaccine administration.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20-milligram capsule to treat Non-24 hour sleep-wake disorder. The 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.To support this diagnosis, the prescriber provided no medical records. 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 requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsule prescribed for your non 24-hour sleep-wake disorder. 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. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation supports the drug was prescribed for non 24-hour sleep-wake disorder in a sighted enrollee. However, medical records to establish a medically accepted indication have not been provided. There are specific clinical determinants of this condition detailed in the International Classification of Sleep Disorders, Third Edition (ICSD-3), in order to establish this diagnosis. The provided records do not establish this diagnosis.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 a request for coverage of Zolpidem Tartrate 5 milligram tablets prescribed for insomnia. The Part D plan denied the request for coverage.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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  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 coverage for Xeljanz XR 11 milligram tablets prescribed daily for ankylosing spondylitis. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a 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 record shows you were prescribed Xeljanz XR for ankylosing spondylitis.  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 a tiering exception for Restasis 0.05 percent emulsion prescribed for dry eyes. The Part D plan denied your request for a tiering exception because Restasis is a brand name Tier 3 drug and there are no drugs for your condition in 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. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Restasis is a brand name Tier 3 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

At issue is a tiering exception request for Clorazepate Dipotassium 15 milligram tablet 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.Clorazepate Dipotassium 15 milligram tablet  is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  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 a tiering exception request for Femring 0.05 milligram/24 hour vaginal ring for 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.This drug is not on the plans formulary. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligrams prescribed each night for insomnia. 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. 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 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: Unfavorable

You requested Trulance 3 milligram tablets prescribed as directed for chronic idiopathic constipation. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.  The requested drug is being provided by your plan under a formulary exception. Trulance is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.    A physician reviewed your appeal and determined that non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets prescribed for small intestinal bacterial overgrowth. The Part D plan denied your request because the medication was not prescribed for a 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 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 Xifaxan. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Clindamycin Phosphate 1 percent gel prescribed daily for hidradenitis suppurativa. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a 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 record shows you were prescribed Clindamycin Phosphate for hidradenitis suppurativa. In review of the Medicare approved compendium, hidradenitis suppurativa is not a medically accepted indication for Clindamycin Phosphate. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Clindamycin Phosphate at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Rifaximin (Xifaxan) 550 milligram tablets prescribed for irritable bowel syndrome with diarrhea. The Part D plan denied the request for 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 information submitted at the reconsideration level. The documentation submitted to the plan during the initial determination and the documentation submitted at reconsideration contain conflicting information regarding the plans coverage requirements. Due to this conflicting information, it is not possible to determine if the plans prior authorization requirements for coverage of this medication have been 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 Belbuca 600 microgram film prescribed daily for pain. The Part D plan denied your request because the documentation did not support an off-formulary 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. In the Reconsideration appeal the prescriber was asked to provide relevant medical records.  No medical records were provided.A physician reviewed your appeal and determined that the plan is not required to cover Belbuca
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is First-Omeprazole 2 milligram/milliliter suspension prescribed for dysphagia. 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 that First-Omeprazole suspension is a bulk powder not eligible for coverage under the enrollee's benefit plan. According to the Food and Drug Administration, First-Omeprazole suspension does not have a National Drug Code that is eligible under Part D. Therefore, we determined the plan is not required to cover the First-Omeprazole suspension. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix 50 microgram/0.5 kit 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 received the Shingrix vaccine at your physicians office. Payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or provider's office. The plan submitted documentation that shows the Shingrix was approved based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the physicians office charged you. We determined that the plan is not required to provide additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Forteo 620 microgram per 2.48 milliliter subcutaneous injection pen prescribed for osteoporosis. 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 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 part D plans prior authorization requirements for coverage of Forteo include a diagnosis of osteoporosis with a T-score of -2.5 or less at the femoral neck, total hip or lumbar spine that has been obtained by dual energy x-ray absorptiometry. Additionally, the enrollee has failed or is intolerant to other available osteoporosis therapy. The submitted medical records indicate that the enrollee is a 78-year-old postmenopausal female with osteoporosis and a history of pathologic fractures. The medical records include results from the enrollees dual energy x-ray absorptiometry scan obtained on October 7, 2020, which show the enrollees left femoral neck T-score was -4.1. Therefore, the enrollee does have a T-score less than -2.5. However, while the records show that the enrollee has tried and failed therapy with Alendronate, there is no documentation to support that the enrollee has failed or is intolerant to the other available osteoporosis therapies.Therefore, the plans prior authorization requirements for coverage of Forteo have not been satisfied. A physician reviewed the appeal and determined that the plan is not required to cover the Forteo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Repatha 140 milligram/milliliter Sureclick 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.Repatha 140 milligram/milliliter Sureclick 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. Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Celecoxib 400 milligram capsules. 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.Celecoxib is a generic drug on Tier 3 of the plans formulary. Your doctor has not addressed why the generic drugs of the same type on the lower tiers of the plans formulary to treat your condition have been tried and failed, or are contraindicated. A physician reviewed the appeal and determined that the plan is not required to cover Celecoxib at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Celecoxib 200 milligram capsule to treat the enrollees condition. 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.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.At reconsideration a diagnosis was not given. No medical records were provided by the prescriber to support a diagnosis. 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.