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

At issue is a tiering exception request for Eliquis five milligram tablet to treat paroxysmal atrial fibrillation.  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. 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. There is no brand drug on a lower eligible tier of the same type that is used to treat your condition. Therefore, your plan is not required to offer you a lower cost share.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20 milligram tablets to treat erectile dysfunction.   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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not FDA approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ninlaro 3 milligram capsules prescribed as directed for an enrollee with multiple myeloma. You requested that the plan provide coverage for a drug that requires prior authorization. The plan did not make a decision within the required timeframe. 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 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 the documentation and included it in our review.The medical records show the doctor prescribed Ninlaro to provide maintenance therapy for an enrollee with multiple myeloma. The enrollee has received prior treatment with Dexamethasone, but the documentation does not support that the enrollee has received prior treatment with Lenalidomide. The documentation shows the enrollee is currently treated with, and tolerating, Velcade and Dexamethasone. 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 Ninlaro.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested approval for Freestyle Libre 14-Day Sensors through the remainder of 2021. 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 documentation shows the plan approved coverage of Freestyle Libre 14-Day Sensors from January 22, 2021, until July 22, 2021. However, this item is eligible for coverage under Medicare Part B. Diabetic supplies not related to the delivery of insulin are considered a Part B benefit. We determined that the plan is not required to cover Freestyle Libre 14-Day Sensors beyond the previously approved date of July 22, 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lantus Solostar. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. Medical records were not provided with the request. There is not a diagnosis listed. Without a diagnosis, we cannot determine if this drug is being prescribed for a medically accepted indication. 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 Alphagan P 0.1% ophthalmic solution. The Part D Plan denied your request for a tiering exception because there were no other similar drugs on a lower cost-sharing tier. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Alphagan P 0.1% ophthalmic solution at a lower cost tier.Alphagan P 0.1% ophthalmic solution is a brand drug on Tier 2 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. Therefore, a tiering exception cannot be granted for the Alphagan P 0.1% ophthalmic solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pimecrolimus 1% cream prescribed daily for lichen simple chronicus, erythema intertrigo. 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. A prescriber statement was submitted. The statement shows the enrollee has intertrigo with atrophy of the skin due to use of corticosteroids. However, there are no medical records to support this information. The Medicare approved compendia do not support the use of this drug for the noted conditions. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Pimecrolimus cream.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Leflunomide 20 milligram tablets twice daily 60 per 30 days for a solid organ (lung) transplant recipient. The Part D plan denied coverage because the drug 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 records submitted at the reconsideration level. The medical records submitted show Leflunomide was prescribed for immunosuppression following a lung transplant. The Federal Food and Drug Administration designated Leflunomide as an orphan drug for the prevention of rejection in patients who have received sold organ transplants. This is confirmed in the Medicare approved compendia.The Plan limits the amount of Leflunomide 20 milligram tablets to 30 tablets for 30 days. The prescriber has indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition.  This is also supported in the compendia. Therefore, an exception to the plans coverage criteria is supported.  Our Physician Reviewer's opinion is that quantity limit criteria are met.Therefore, the documentation submitted supports that the plan's coverage criteria for the medication have been satisfied. A physician reviewed your appeal and determined that the plan is required to cover Leflunomide at the requested dosage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Victoza 0.6 mg/ml pen injector 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.Victoza 0.6 mg/ml pen injector 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

At issue is Lyrica 75 milligram tablets 4 times/day.  At initial determination and redetermination the diagnosis of unspecified osteoarthritis unspecified site was given. 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.At reconsideration a diagnosis of neuropathy was given. No medical records were provided by the prescriber to support this 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Toviaz eight milligram 24 hour extended release 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.Toviaz is a brand drug on Tier 4 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

At issue is Atorvastin calcium 20 milligram prescribed for unknown diagnosis. The plan provided documentation showing the claims were allowed at the time of purchase for the plans cost share amount. The enrollee is requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.We conducted an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased Atorvastin calcium from an out-of-network pharmacy for an amount that is less than or equal to the required copayment amount. We reviewed the plans formulary and Evidence of Coverage and determined that the plan was correct in the calculation of copay and is not required to provide additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azithromycin 250 milligram prescribed for unknown diagnosis. The plan provided documentation showing the claims were allowed at the time of purchase for the plans cost share amount. The enrollee is requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.We conducted an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased  Azithromycin from an out-of-network pharmacy for an amount that is less than or equal to the required copayment amount. We reviewed the plans formulary and Evidence of Coverage and determined that the plan was correct in the calculation of copay and is not required to provide additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dorzolamide hydrochloride and Timolol maleate prescribed for unknown diagnosis. The plan provided documentation showing the claims were allowed at the time of purchase for the plans cost share amount. The enrollee is requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.We conducted an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased Dorzolamide hydrochloride and Timolol maleate from an out-of-network pharmacy for an amount that is less than or equal to the required copayment amount. We reviewed the plans formulary and Evidence of Coverage and determined that the plan was correct in the calculation of copay and is not required to provide additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

 At issue is  Lisinopril 10 milligram prescribed for unknown diagnosis. The plan provided documentation showing the claims were allowed at the time of purchase for the plans cost share amount. The enrollee is requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.We conducted an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased Lisinopril from an out-of-network pharmacy for an amount that is less than or equal to the required copayment amount. We reviewed the plans formulary and Evidence of Coverage and determined that the plan was correct in the calculation of copay and is not required to provide additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin hydrochloride 500 milligram prescribed for unknown diagnosis. The plan provided documentation showing the claims were allowed at the time of purchase for the plans cost share amount. The enrollee is requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.We conducted an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased Metformin hydrochloride from an out-of-network pharmacy for an amount that is less than or equal to the required copayment amount. We reviewed the plans formulary and Evidence of Coverage and determined that the plan was correct in the calculation of copay and is not required to provide additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisone acetate 1% prescribed for unknown diagnosis. The plan provided documentation showing the claims were allowed at the time of purchase for the plans cost share amount. The enrollee is requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.We conducted an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased Prednisone acetate from an out-of-network pharmacy for an amount that is less than or equal to the required copayment amount. We reviewed the plans formulary and Evidence of Coverage and determined that the plan was correct in the calculation of copay and is not required to provide additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium phosphate 500 milligram tablet prescribed for unknown diagnosis. The Part D plan denied your request for coverage under Medicare Part D because this drug is not listed on the National Standard Data Element file, or the National Drug code listed on the file has a marketing end date. 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.According to the Food and Drug Administration,  Potassium phosphate is not an approved drug in the market category. Therefore, it is not eligible for coverage or under Medicare Part D.  We determined the plan is not required to cover and provide reimbursement for the K-Phosphorus. 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 Shingrix 50 micrograms prescribed for vaccination. The Part D plan denied the request for additional reimbursement. We received a request to reconsider the appeal. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The plan submitted documentation that shows coverage was allowed for the Shingrix injection. The plan calculated reimbursement to the provider based on the approved cost of the drug, minus your required co-payment amount. According to the plan, the provider charged you more than the approved cost of the drug. We determined the plan is not required to reimburse you for the amount you paid to the provider. You should request reimbursement from your provider for the amount charged above the approved cost.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine Hydrocloride 25 milligram tablets prescribed for nausea. The Part D plan denied the request. We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The proescriber stated that the patient has been stable on current medication since 2015 and the patient will have increased nausea without medication. However, there is no indication that medication with less risk in older adults was tried or reasons a non-high risk medication might be contraindicated. There also was no documentation of the drug being requested for antiemetic therapy in postoperative patients or for motion sickness and that the benefit of therapy with this prescribed medication outweighs the potential risks for the patient. Therefore, the prior authorization requirements were not met.   Our Physician Reviewer determined that the plan is not required to cover Promethazine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Leflunomide 20 milligram tablet prescribed daily for rheumatoid arthritis. The Part D plan denied your 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.Leflunomide is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers for your 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 Baclofen 5 milligram tablets prescribe to treat muscle spasms. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The Medicare approved compendia supports the use of this drug for management of spasticity and its sequelae secondary to severe chronic disorders such as multiple sclerosis and other types of spinal cord lesions. The documentation provided does not show the requested drug is medically indicated for the enrollee. Our Physician Reviewer determined that the plan is not required to cover Baclofen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent ointment prescribed as needed for neuropathic pain. The Part D plan denied your request because it does not meet the criteria of 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Lidocaine 5 percent ointment as needed to treat your neuropathic pain. However, the Medicare approved compendia do not support the use of this drug, in this form,  for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5 percent ointment because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta 50 milligram tablets to treat chronic pain. The Part D plan denied the request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read 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 has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewers opinion is that formulary exception criteria are not met.