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

At issue is Simponi Aria 50 milligrams per 4 milliliter vial to treat rheumatoid arthritis. 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 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 reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sodium Phenylbutyrate Powder 3 grams per teaspoon for amyotrophic lateral sclerosis. 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 Sodium Phenylbutyrate Powder was prescribed for amyotrophic lateral sclerosis. 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 Sodium Phenylbutyrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vagifem 10 microgram tablets prescribed for postmenopausal vaginal dryness secondary to atrophic vaginitis. 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 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 for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. We received the documentation and included it in our review.You submitted a supporting statement and medical records. The medical records support that you have prescribed Vagifem to treat the enrollees postmenopausal vaginal dryness. Medicare approved compendia supports the use of the requested drug for this condition.The records show that you cannot take other drugs on your plans formulary for your condition. Specifically, you have tried Estring, Yuvafem, and Premarin, which caused itching and severe allergic reactions. In addition, you indicated that the enrollee attempted to trial Osphena, but was informed of a possible allergic reaction by the pharmacy. The medical records support the enrollees lactose intolerance. However, drugs to treat vaginal dryness are excluded drugs.A physician reviewed your appeal and determined that the plan is not required to cover Vagifem.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Incruse Ellipta inhaler. The Part D plan denied your request for a tiering exception. We received a reconsideration request from the plan. 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 shows Incruse Ellipta inhaler 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 for 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 cover Incruse Ellipta inhaler.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symbicort aerosol. The Part D plan denied your request for a tiering exception. We received a reconsideration request from the plan. 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 shows Symbicort 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 for 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 cover Symbicort.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Efudex Cream 5% to treat a skin lesion. 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 your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The records do not show why you cannot take other drugs on the plans formulary for your condition. A request was made to the prescriber asking for additional information such as your diagnosis and other drugs tried, but we did not receive any additional records. A physician reviewed your appeal and determined that the plan is not required to cover the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prescribed Pulmozyme 1 milligram/ milliliter solution for cerebral palsy. The Part D plan denied your request because it could not confirm that the enrollee was a resident of a long-term care facility.  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. The documentation shows the doctor prescribed Pulmozyme to treat cerebral palsy. The documentation does not show that the enrollee resides in a long term care facility. This drug is eligible for coverage under Medicare Part B. We determined that the plan is not required to cover Pulmozyme.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aubagio 14 milligram tablets prescribed to treat multiple sclerosis. 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 your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The records do not show why you cannot take other drugs on the plans formulary for their condition. There are multiple drugs listed in the formulary that the prescriber did not address that include disease-modifying agents. A request was sent to the prescriber for additional information but we did not receive and additional records. A physician reviewed your appeal and determined that the plan is not required to cover the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Synthroid (Levothyroxine Sodium) 75-microgram tablets prescribed daily for hypothyroidism. The Part D plan denied your request for a tiering exception because Synthroid is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative 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. We also researched Medicare systems and reviewed the enrollment data available. The record shows Synthroid is being prescribed for hypothyroidism. The Medicare approved compendia support the use of the requested drug for your condition. The plan shows Synthroid 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: Favorable

You requested Brukinsa 80 milligram capsules prescribed four times daily for Waldenstrom macroglobulinemia. The Part D plan denied your request because the medication is 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 records show you prescribed Brukinsa to treat the enrollees Waldenstrom macroglobulinemia. Medicare approved peer reviewed medical literature does support the use of this drug for this condition. Specifically, a Phase 3 trial compared Zanubrutinib to Ibrutinib, which showed similar efficacy with less adverse events, including hemorrhage and atrial arrhythmias. The enrollee is at risk for both of these complications, as the enrollee is on anticoagulation for atrial flutter. The enrollee is also not a candidate for Rituxan as it was tried and failed. Furthermore, the enrollee is not a candidate for Bendamustine based on age and performance status. Thus, Zanubrutinib would be the safest treatment option. An oncologist reviewed your appeal and determined that the plan is required to cover Brukinsa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Skyrizi 150 milligrams subcutaneous prescribed as directed for psoriasis. The Part D plan denied coverage because chart notes were not received. 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 records submitted at the reconsideration level.We asked the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why this medication was needed. We received the documentation and included it in our review.The prescriber has provided office notes and a statement. The prescriber stated you tried Methotrexate, Cyclosporine, and Retin-A. However, the medical records do not support this statement. The prior approval criteria are not met.A physician reviewed your appeal and determined that the plan is not required to cover the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nulojix 250 milligram solution prescribed two intravenously every 28 days for unspecified complication of kidney transplant. The Part D plan denied the request because drugs that could be covered under Part B are not eligible to be covered under the Part D benefit. 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.Nulojix is an immunosuppressive agent and is being given following a kidney transplant. However, this drug is eligible for coverage under Medicare Part B.We determined that the plan is not required to cover Nulojix.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ongentys 50 milligram capsule prescribed daily for Parkinsons disease. 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.Ongentys is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover Ongentys. There are no lower tiered brand drugs of the same type to treat your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Spriva 18 micrograms CP Handinhaler prescribed for your condition. The case was auto-forwarded from the plan.. 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.Spriva 18 micrograms CP Handinhaler is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol 25 milligram tablet 90 day supply. The plan provided documentation showing this claim was covered 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 the enrollee purchased Metoprolol on January 07, 2021 from a preferred retail pharmacy for an amount that is less than or equal to the required copayment amount. The amount of the copayment was based on the drug's tier and place of purchase. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We have determined that reimbursement for the copay amount cannot be allowed for the Metoprolol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Doxycycline Monohydrate for use in a compound prescribed for halitosis. The Part D plan denied your request 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 information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed a compound that includes Doxycycline Monohydrate for halitosis. The compound drug at issue is comprised of Doxycycline Monohydrate, Nystatin Suspension, Diphenhydramine, and Hydrocortisone. The Medicare approved compendia do not support the use of the drugs in the compound 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 Boostrix 2.5-8-5/.5 injection administered to you in the hospital. The Part D plan denied your request for additional reimbursement for Boostrix. We received a request for reconsideration. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The record shows you received Boostrix injection for medical care at the hospital. The plan submitted information showing the drug was allowed 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 out-of-network pharmacy (i.e., hospital) charged you. In this case, the total charge for the drug was $112 minus your copay of $47 plus the amount of out-of-network fee of $19. Records indicate you were reimbursed $46 for the difference. Therefore, the plan provided coverage and reimbursement in accordance with the Part D plan rules for out-of-network reimbursement. We determined that the plan is not required to reimburse you for the out-of-network fee.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Orencia 125 milligrams/milliliter syringe prescribed for giant cell arteritis. The Part D plan denied your request because the Food and Drug Administration has not approved this drug for your diagnosis. 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. Your medical records show your doctor prescribed Orencia to treat your giant cell arteritis. However, the Medicare approved compendia do not support a Food and Drug Administration approved use of this drug for your condition. The plan's coverage criteria are not satisfied.A physician reviewed your appeal and determined that the plan is not required to cover Orencia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Suboxone sublingual film prescribed for low back pain. The Part D plan denied a request for this drug because you did not have 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 Suboxone was prescribed to treat chronic pain. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Suboxone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for the cost of a Menveo vaccine received for meningitis infection prevention. 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. Medicare approved compendia do not support a Food and Drug Administration approval of the use of this vaccine in adults over 55 years of age. Therefore, it is not eligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to provide reimbursement for the Menveo vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix 50 micrograms prescribed for shingles vaccination. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The records show you have a receipt and are requesting reimbursement. The plan submitted documentation that shows coverage was provided to the physicians office for the vaccination. The plan calculated reimbursement 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 out-of-network clinic charged you.We determined that the plan is not required to provide additional reimbursement for the Shingrix vaccine. The plan provided coverage and reimbursement in accordance with your plans out-of-network rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atomoxetine Hydrochloride 100 milligram capsules for the diagnosis of attention-deficit hyperactivity disorder. 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. We also researched Medicare systems and reviewed the enrollment data available. Atomoxetine Hydrochloride is a generic drug on Tier 3 of the plans formulary. There are no generic 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 Reviewers opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 10 milligram capsules to treat poor appetite in an enrollee with cystic fibrosis. 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.
Appeal type: Prescription Drug
Decision: Favorable

You requested Calcitriol 0.5 microgram capsules prescribed daily for chronic kidney disease stage three and secondary hyperparathyroidism. The Part D plan denied your request because 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 information submitted at the reconsideration level. Your medical records submitted at reconsideration, show your doctor prescribed Calcitriol to treat chronic stage 3a kidney disease. The Medicare approved compendia supports the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is required to Calcitriol.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Losartan Potassium 50 milligram tablets prescribed as 135 tablets for 90 days for hypertension. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. 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 plans coverage rules indicate that Losartan Potassium 50 milligram tablets are covered at a maximum of 2 tablets per day. The amount requested is within the plans maximum daily quantity limits and is within the Food and Drug Administration dosing guidelines for hypertension.  A physician reviewed your appeal and determined that the plan is required to cover 135 tablets for 90 days of Losartan Potassium.