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

You requested Letairis 10 milligram tablets prescribed as directed for pulmonary arterial hypertension  World Health Organization Group I. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the physician prescribed Letairis for pulmonary arterial hypertension  World Health Organization Group I. However, the 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 the Letairis.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Feraheme 510 milligram/17 milliliter solution prescribed for anemia. 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. According to Medicare rules, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Feraheme. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dilantin ER 100 milligram capsules prescribed three times daily for localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus. The Part D plan denied your 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. Dilantin ER 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 to treat the enrollee's condition. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

You requested Imatinib mesylate 400 milligram tablets prescribed to treat your condition. The Part D plan indicated they approved your request for a formulary exception; however, the decision was not timely.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the plan has granted your request for Imatinib mesylate 400 milligram tablets. The approval was not made timely. The requested drug has been approved coverage under Medicare Part D from February 24, 2021, through February 24, 2023.A physician reviewed your appeal and determined that the plan is required to cover Imatinib mesylate 400 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed for 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 tiers would not work for you. However, we did not receive the documentation.Lidocaine 5% patch is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why similar medications on the lower tiers 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

You requested Acyclovir 800 milligram tablets purchased outside of the United States. 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. According to the plans Evidence of Coverage, drugs purchased outside the United States and its territories are not covered. We determined that the plan is not required to cover the Acyclovir or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Moxifloxan hydrochloride 0.5% solution purchased outside of the United States. 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. According to the plans Evidence of Coverage, drugs purchased outside the United States and its territories are not covered. We determined that the plan is not required to cover the Moxifloxan hydrochloride or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prednisolone acetate 1% solution purchased outside of the United States. 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. According to the plans Evidence of Coverage, drugs purchased outside the United States and its territories are not covered. We determined that the plan is not required to cover the Prednisolone acetate or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolastin-C 1,000 milligram vial prescribed as directed for alpha-1-antitrypsin deficiency, phenotype IS. The Part D plan denied coverage.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 levelThe medical records show you were prescribed Prolastin-C to treat your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided do not show the coverage criteria have been met. 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 Prolastin-C.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hetlioz 20 milligram prescribed once a day for circadian rhythm sleep disorder. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Hetlioz for your circadian rhythm sleep disorder. 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 and the plans coverage criteria has not been satisfied, coverage cannot be allowed. 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 Viibryd 40 milligram oral tablet prescribed daily for depression. 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.Viibryd 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. 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 Viibryd.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Azopt 1% Eye Drops 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.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.Our physician reviewers opinion is that Azopt 1% Eye Drop is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram tablet prescribed daily for circadian rhythm sleep disorder, free running type. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.The records show Hetlioz was prescribed to treat circadian rhythm sleep disorder, free running type. The Medicare approved compendia do support the use of this drug for this condition. However, the plan requires prior authorization criteria be met before they will cover the drug. The documentation provided does not show you have satisfied the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrochlorothiazide 12.5 milligram tablets 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.The record shows you purchased the Hydrochlorothiazide at an out-of-network pharmacy. The plans Evidence of Coverage indicates reimbursement is 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 charged you. We determined that the plan is not required to further reimburse you for the Hydrochlorothiazide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipratropium bromide 0.6% solution 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.The record shows you purchased the Ipratropium bromide at an out-of-network pharmacy. The plans Evidence of Coverage indicates reimbursement is 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 charged you. We determined that the plan is not required to further reimburse you for the Ipratropium bromide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Myrbetriq ER 25 milligram tablets prescribed daily for overactive bladder. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Myrbetriq ER 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. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Dupixent 300 milligram per 2 milliliter prefilled syringe for subcutaneous injection. The Part D plan denied your request stating that the medication was being prescribed for a non-medically accepted indication.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 medical records submitted at reconsideration indicate that Dupixent is being prescribed in the management of the enrollees inadequately controlled chronic sinusitis with nasal polyposis. As outlined in the Medicare approved compendia, this a medically accepted indication for the use of Dupixent.However, Dupixent is not included in the Part D plans formulary. The prescriber has not sufficiently addressed why all alternative drugs that are included in the plan to treat the enrollees condition have been tried and failed or would likely not be as effective as the requested drug or would likely cause adverse reactions or other harm. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Multaq 400 milligram tablets prescribed for unspecified atrial fibrillation. The Part D plan denied your request for a tiering exception because Multaq is a brand name Tier 4 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 plan shows Multaq is a brand name Tier 4 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Hydrocortisone 5 milligram tablet to treat Addisons 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.Hydrocortisone 5 milligram tablet is a generic drug on Tier 2 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

You requested Tretinoin 0.025 percent cream prescribed for chloasma. The Part D plan denied your request because Medicare has excluded Part D coverage for agents used for cosmetic purposes. We received a 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 determined that the plan is not required to cover Tretinoin because agents used for cosmetic purposes are excluded from coverage. If you purchased drugs/agents that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug/agent. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20-milligram capsule to treat circadian rhythm sleep disorder, free running type. The Part D plan dismissed the case.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

You requested Alprazolam 0.25 milligram tablets prescribed for unknown diagnosis. The Part D plan denied your request.We received a case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased the Alprazolam from a network pharmacy. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The documentation does not include a receipt indicating you paid for the Alprazolam in full. Therefore, we determined that the plan is not required to reimburse you without the required documentation. Please submit proof of payment to your plan for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Cyclobenzaprine 10 milligram tablets prescribed for acute skeletal muscle pain. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Cyclobenzaprine for acute skeletal muscle pain. However, medical records were submitted indicate the drug was ordered for myofascial pain that is chronic. The medical records support the diagnoses of chronic pain syndrome, lumbar pain and lumbar facet arthropathy. In review of the Medicare approved compendium, chronic myofascial pain is not a medically accepted indication for Cyclobenzaprine. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Cyclobenzaprine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Clonazepam 0.5 milligram tablets. The Part D plan forwarded your request to us for review.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. Clonazepam is a generic drug on Tier 1 of the plans formulary. This is the plans lowest cost tier. Therefore, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Clonazepam at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone 100% micronized powder prescribed for osteoporosis. The Part D plan denied your request because the requested drug is not considered a Part D covered 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 information submitted at the reconsideration level. We determined that the plan is not required to cover Testosterone micronized powder because it is not an approved Food and Drug Administration drug. A covered Part D drug must be approved by the Food and Drug Administration. 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 payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dofetilide 125 microgram capsules prescribed for atrial fibrillation. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Dofetilide is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan, 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.A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5 milligram tablet to treat benign prostatic hyperplasia and benign prostatic hyperplasia lower urinary tract symptoms. 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and medical records have not been provided. Therefore, an exception to the plans coverage criteria is not supported.Our physician reviewer's opinion is that formulary exception criteria are not met.