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

At issue is Lidocaine-Prilocaine 2.5/2.5% Cream. 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. We also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.  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 Proscar 5 milligram tablets prescribed for an unknown diagnosis. The Part D plan denied your request for additional reimbursement. 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.You submitted documentation that shows you requested a refill of Proscar from your local plan pharmacy and it was mailed to you, after notification that it was ready to be picked up. According to your plans 2020 Evidence of Coverage, you have a copay for specialty tier drugs of $75 for a 61-100 day supply at a plan pharmacy. If you choose to request your drug through the mail order website, or contact phone number, the copay is $50. The submitted documentation indicates your drug was requested from a retail pharmacy, not through mail order and your copay was $75. Therefore, we determined the plan's charge was correct and no further reimbursement is required.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benicar HCT 12.5 milligram tablet prescribed as directed to treat hypertension. 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 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 that your doctor prescribed Benicar HCT to treat your condition. Your medical records do not show all alternative drugs on the plans formulary, to treat your condition, have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Benicar HCT because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% external patch to treat chronic pain with history of multiple spinal surgeries. 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 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 your 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: Favorable

At issue is Febuxostat 80 milligram tablet to treat gout. The Part D plan denied the request. The requested drug is not on the plans formulary. We received an expedited 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 provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide-Formoterol 160-4.5 microgram inhaler to treat chronic obstructive pulmonary disease. The Part D plan denied the request. The requested drug is not on the plans formulary. We received an expedited 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.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records to show why the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. We received the documentation and included it in our review.The prescriber stated the alternative required by the plan (brand Symbicort aerosol inhaler) would be as effective as the requested drug. Therefore, an exception 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 a tiering exception request for Rasagiline 1 milligram tablet to treat Parkinsons disease. The Part D plan denied the request. We received an expedited 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.Rasagiline 1 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 Fentanyl 100 microgram/hour transdermal patch prescribed for the enrollees chronic low back pain. 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. The plan further denied your request for a quantity limit 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 records submitted at the reconsideration level. The documentation supports the drug was prescribed for chronic low back pain. Your doctor submitted a supporting statement. The statement indicates you are to use the Fentanyl patches every 48 hours as needed. The Medicare approved compendia do not support the use of this drug as needed. As the drug cannot be allowed as prescribed, a quantity limit exception cannot be granted.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 Spiriva Handihaler inhalation capsule 18 micrograms to treat chronic obstructive pulmonary disease. 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 to show why the medication was needed. Specifically, we asked for records to show why other drugs on the plan's formulary would not work. However, we did not receive the documentation.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 is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

Testosterone Solution 30 mg/actuation was requested to treat the enrollees condition.  The Part D plan denied your request because medical necessity was not established.  As well, the requested drug has prior authorization criteria.  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.A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  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 requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Shingrix 50 micrograms per 0.5 milliliter vaccine injection to treat the enrollees diagnosis. The Part D Plan denied the request.We performed an independent and de novo review. We reviewed all documentation submitted. The record shows the enrollee received the Shingrix vaccine in the physicians office. The records contain proof of payment.We determined that the plan is required to reimburse you for the Shingrix vaccine. The Medicare rules above have been met.In conclusion, the decision of the QIC is favorable.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone Cypionate 200 milligram/milliliter injection to treat 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. 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. Per the compendia, The safety and efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism.' A physician reviewed your appeal and determined that the plan is not required to cover Testosterone Cypionate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Leflunomide 10 milligram tablets prescribed for rheumatoid arthritis. 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. We asked your prescriber to send us information about your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why similar medications on the lower tier would not work for you. . Leflunomide is a generic drug on Tier 3 of the plans formulary. Your doctor did not address why the lower tier medications would not work for you. All generic drugs on lower tiers have not been tried. 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 Opium Tincture 10 milligram/1 milliliter prescribed daily for diarrhea. 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. Opium is a brand drug on Tier 3 of the plans formulary. Brand name drugs are eligible for tiering exceptions to the lowest applicable cost-sharing associated with brand name alternatives. There are no brand drugs of the same type on the lower cost sharing tiers to treat the enrollees condition. 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 Xyrem 500 milligram/milliliters solution to treat spasmodic dysphonia. 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 does 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 Propanolol hydrochloride 10 milligram tablets prescribed daily 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 plan submitted documentation that shows you were in the initial coverage stage of your Part D benefit when this drug was purchased. According to your plans Evidence of Coverage, Propanolol hydrochloride is a tier 2 drug with a copay of $36, in the initial coverage stage. The record shows the full price of the drug was less than the $36 copay amount. Therefore, your charge was based on the total cost of the drug. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Savella 50 milligram tablet to treat pain. The case was auto-forwarded by the plan.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: Unfavorable

At issue is Entresto 24-26 milligram tablets to treat left-sided congestive heart failure. 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 statement provided states the enrollee has a history of angioedema. The chart note provided states the enrollee has no history of angioedema in the records and there is medical record documentation that the enrollee is on Entresto. There is not information regarding the New York Heart Association class the enrollee was in prior to the initiation of Entreso. It could not be determined whether the plans coverage criteria have been satisfied. A physician reviewed your appeal and determined that the plan is not required to cover Entresto.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pregabalin 25 milligram oral capsule prescribed daily for low back pain without sciatica. 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 Pregabalin was prescribed to treat bilateral low back pain with bilateral sciatica, unspecified chronicity. However, the Medicare approved compendia do not support the use of this drug for this condition. As such, 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 Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram oral tablet prescribed twice daily for atrial fibrillation. The Part D plan denied your request for a tiering exception. We received an expedited 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.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. There are no lower tiered brand drugs of the same type to treat the enrollee's condition.A physician reviewed your appeal and determined that the plan is not required to cover Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dextroamphetamine-Amphetamine to treat attention deficit hyperactivity disorder. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Namzaric Extended Release 28milligram-10 milligram Capsules prescribed to treat dementia, unspecified. The Part D plan did not provide a timely decision. 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 regulations and Medicare approved compendia. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees condition. The drug is not approved by the food and drug administration to treat the diagnoses submitted. 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 Namzaric.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Torsemide 20 milligram tablets prescribed as directed for acute on chronic diastolic (congestive) heart failure. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We asked the prescriber to send us a supporting statement and medical records showing why Torsemide is medically necessary. However, we did not receive the documentation.The available documentation does not show why the enrollee cannot take other drugs on the plans formulary for their condition.A physician reviewed your appeal and determined that the plan is not required to cover Torsemide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ztlido 1.8% patches. The Part D plan denied a request for this drug. 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 documentation indicates that Ztlido 1.8% patches were prescribed to treat pain for intervertebral disc degeneration and mid-cervical disc disorder. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s). 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 Ztlido 1.8% patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 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.Eliquis is a brand drug on Tier 3 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.