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

You requested Amiodarone 200 milligram tablets prescribed for an unknown diagnosis. The Part D plan denied your request for additional reimbursement. We received an auto-forwarded reconsideration request from the plan.We received a case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation that shows you were in the initial coverage stage of the Part D benefit. The plan calculates reimbursement based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The record shows the plan paid its share of the cost for the Amiodarone and the remaining amount was your copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eliquis 5 milligram tablets prescribed for an unknown diagnosis. The Part D plan denied your request for additional reimbursement. We received an auto-forwarded reconsideration request from the plan.We received a case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows you were in the initial coverage stage for part of the cost for this drug and entered the coverage gap stage for the remaining amount. According to your plans Evidence of Coverage, reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you while you are in the initial coverage stage. During the coverage gap stage you pay 25% of the price for brand name drugs and a portion of the dispensing fee, if applicable. The record shows the plan paid its share of the cost for the Eliquis, and your cost share was calculated based on a portion of copay in the initial coverage stage and 25% of the coverage gap discount for the remaining amount. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue Taltz 80 milligrams/milliliter auto injector to treat plaque psoriasis. 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 provided a statement. However, it did not include a 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 Hetlioz 20 milligram capsules prescribed as directed for non-24 hour sleep/wake cycle. The Part D plan denied coverage because the prior authorization criteria were not met. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The prescriber statement 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 Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Sildenafil Citrate 20 milligram oral tablet. 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 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. We also researched Medicare systems and reviewed the enrollment data available.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 received the documentation and included it in our review.The medical records show your doctor prescribed Sildenafil Citrate to treat pulmonary hypertension. The Medicare approved compendia do not support the use of this drug for your condition. The plan requires a diagnosis of pulmonary arterial hypertension confirmed by a right heart catheterization before they will cover the requested drug. 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 Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Diclofenac Sodium 1% gel. 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. We performed an independent and de novo review. To make our decision, we read the case file carefully. Medical records were requested during this review and received. We reviewed all documentation submitted.The prior authorization requirements listed for Diclofenac Sodium 1% gel include the enrollee has osteoarthritis pain in joints susceptible to topical treatment such as feet, ankles, knees, hands, wrists, or elbow and treatment with the requested drug is necessary due to concern of an intolerance or a contraindication to oral nonsteroidal anti-inflammatory drugs (NSAIDs). The prescriber statement and medical records submitted during this review show that Diclofenac Sodium 1% gel was prescribed for pain due to post traumatic osteoarthritis of the right wrist. In the submitted progress notes dated March 3, 2021, the prescriber notes that the enrollee is going to be placed on a topical anti-inflammatory medication for her right wrist, which is still sore and stiff. The prescriber also notes that hopefully the topical medication will not upset her stomach as oral anti-inflammatory medications seem to do.  The medical records do confirm osteoarthritis pain in a joint susceptible to topical treatment, the right wrist. Additionally, the records support that the drug was prescribed due to the prescribers concern of the enrollees intolerance to oral nonsteroidal anti-inflammatory drugs.  Therefore, the plans prior authorization requirements have been satisfied.A physician reviewed your appeal and determined that the plan is required to the Diclofenac Sodium 1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide prescribed to treat collagenous colitis. The Part D plan auto-forwarded this case.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.We asked the prescriber to send us a prescriber statement and medical records to show why the enrollee needs this medication. We received the documentation and included it in our review.The documentation available 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 your appeal and determined that the plan is not required to cover Budesonide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prescribed Sodium fluoride 5000 toothpaste. The Part D plan denied your request for 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 determined that the plan is not required to the Sodium fluoride 5000 toothpaste because it is an over-the-counter drug. Nonprescription, or over-the-counter drugs, are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that reimbursement cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epclusa tablets prescribed for chronic viral hepatitis C. The Part D plan auto-forwarded this case.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.We asked the prescriber to send us a prescriber statement and medical records to show why the enrollee needs this medication. We did not receive the documentation requested.The documentation available does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and medical records have not been provided.A physician reviewed your appeal and determined that the plan is not required to cover Epclusa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acitretin 25 milligram capsule to treat pityriasis rubra pilaris.  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. 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 Vemlidy 25 milligram tablets to treat the diagnosis of chronic Hepatitis B virus (without compensated liver disease). The Part D plan denied the request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The 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 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: Unfavorable

At issue is Oxycodone Hydrochloride ER 30 milligram tablets prescribed for chronic pain. The Part D plan denied coverage because the prior authorization requirements were not met. We received a reconsideration request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level. Medical records were requested from your doctor during this appeal, but not received.The submitted documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed all of the plans requirements for coverage of this medication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone 1.62% gel prescribed daily for late-onset (age-related) hypogonadism. 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.Your medical records show your doctor prescribed Testosterone for late-onset (age-related) hypogonadism. The Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Testosterone.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Dupixent 300 milligrams per 2 milliliter pen to be given as directed for bullous pemphigoid. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records. A reply from the prescriber was received and we included it in our review.The use of the requested drug to treat the provided diagnosis has an orphan drug designation. This means it has a medically accepted indication and may be a covered drug under a Part D plan. The documentation satisfies the plans coverage criteria. 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 Coreg Extended Release 10 3 milligram capsules prescribed to treat hypertension. 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 prescriber indicates the enrollee had tried the alternative medication, carvedilol, and it caused the enrollees blood pressure to drop. However, there was no supporting medical records submitted documenting the carvedilol phosphate extended release oral capsule trial and failure as required by the plan. Therefore, the prior authorization requirements were not met.   A physician reviewed your appeal and determined that the plan is not required to grant your request for Coreg.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tradjenta 5 milligram tablets to treat type 2 diabetes with diabetic polyneuropathy. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The physician submitted a supporting statement. The prescriber statement indicates that the enrollee has uncontrolled diabetes and kidney disease; therefore, the formulary alternatives are contraindicated. However, medical records have not been submitted for review to substantiate the issues raised. Therefore, the documentation available does not support the enrollee has satisfied the plan's coverage criteria.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Revlimid 5 milligram capsules prescribed to treat discoid lupus erythematosus. The Part D plan denied your request. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We 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 Revlimid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Pregabalin 25 milligram capsules prescribed for neuropathic pain due to intervertebral disc displacement, lumbar region. The Part D Plan denied your request because the documentation did not explain why the plans alternative drugs in lower tiers would not work just as well. 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. Pregabalin is a generic drug on Tier 3 of the plans formulary. The submitted medical records do not sufficiently address why all of the generic drugs of the same type on the lower tiers of the plans formulary to treat the enrollees condition have been tried and failed, or are contraindicated. Therefore, the plan is not required to grant a tiering exception for the Pregabalin.A physician reviewed your appeal and determined that the Pregabalin is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Klonopin 2 milligrams tablets. The Part D plan denied your request to cover this drug at a lower tier cost. The plan indicated this is a non-formulary approved drug and cannot be provided at a lower tier cost. We received an expedited reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows Klonopin was prescribed; however, Klonopin is a non-formulary drug approved for coverage by the plan, and 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 for the Klonopin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methyphenidate Hydrochloride to treat lethargy, cognitive decline and fatigue due to depression. 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

At issue is Repatha Sureclick 140 milligrams/milliliter injection for primary hyperlipidemia. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation satisfies the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Prednisone 5 milligram tablets prescribed daily for kidney transplant. The Part D plan denied your request because you were eligible for Medicare Part B coverage at the time of transplant. 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. The record shows you received a kidney transplant on January 11, 1994, which was covered under your private insurance plan. According to Medicare enrollment records, you were not entitled to Medicare Part A coverage at the time of the transplant. Therefore, your transplant is not considered a Medicare covered transplant and Prednisone is not eligible under Medicare Part B. Therefore, we determined that the Part D plan is required to cover the Prednisone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patches prescribed for chronic back pain/polyradiculopathy. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Lidocaine for chronic back pain/polyradiculopathy. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested OxyContin 15 milligram tablets prescribed as directed. 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 medical records showing the enrollees need for this medication. However, we did not receive the documentation.The prescriber statement shows the enrollee has rheumatoid arthritis with chronic pain, lumbar spondylosis with radiculopathy, and cervical spondylosis with radiculopathy. However, medical records were not provided to support the diagnoses reported. 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 plan is not required to cover OxyContin.