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

At issue is Tacrolimus 0.1% ointment prescribed for atopic dermatitis and lichen planus. 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 level. The documentation indicates Tacrolimus was originally prescribed for lichen planus. The prescriber submitted medical records to support the drug was prescribed for atopic dermatitis and lichen planus including the scalp, face, ears, and eyelids. Furthermore, the enrollee satisfies the plan's coverage criteria. The enrollee was previously treated with a topical prescription steroid with an inadequate response.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clonidine 0.3 milligram/24 hour patch prescribed to treat your condition. 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.Clonidine 0.3 milligram/24 hour patch is a generic drug on Tier 3 of the plans formulary. There are no 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

You requested Dexamethasone sodium phosphate bulk powder compounded to a nasal spray for unknown diagnosis. The Part D plan denied your request.  We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the Dexamethasone sodium phosphate bulk powder is a component of a compounded nasal spray. Medicare Part D does not cover non-prescription drugs. Some of the ingredients within the compounded drug are over-the-counter drugs and are not eligible for Part D coverage. We also found that the bulk powder is not approved by the Food and Drug Administration as safe and effective. Therefore, we determined the plan is not required to cover the compounded drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed as directed for your condition. The Part D plan denied the 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 was asked questions to clarify the diagnosis, medical history, and to provide documentation to support medical necessity. The prescriber was also asked questions to address the plans prior authorization criteria. We did not receive a response from the prescriber. Based upon the current record, 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 Temazepam 15 milligram capsules prescribed as directed for insomnia. The Part D plan denied your 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tizanidine Hydrochloride 4 milligram tablets prescribed for myofascial muscle pain or muscle spasms in the paraspinous muscles of the lumbar area. 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. A request was submitted to the prescriber to provide medical records to support why all formulary alternatives would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm.  A reply from the prescriber was not received. 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 Omnaris 50 microgram nasal spray prescribed daily for allergic rhinitis. The Part D plan denied your request because the documentation did not support an off-formulary 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Omnaris.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin 15 milligram oral tablet prescribed daily for chronic pain syndrome. The Part D plan denied your request for a tiering. 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. Oxycontin is a brand drug that is not on the plans formulary. Medicare has already granted a formulary exception for the drug. A tiering exception cannot be allowed for a drug that is not on the plans formulary. 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 a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humira 80 milligram/0.8 milliliter and 40 milligram/0.4milliliter starter pen injector kits prescribed as directed for psoriasis vulgaris. 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,Your medical records show your doctor prescribed Humira to treat your psoriasis vulgaris. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plan requires an intolerance or contraindication to conventional therapy before they will cover the requested drug. The prescriber has not sufficiently indicated why all alternatives required by the plan would likely cause harm or not be as effective for the enrollee as 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 Humira because the Plans prior authorization requirements were not met. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Measles mumps rubella II injection prescribed for vaccination. 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 you received the Measles mumps rubella II vaccine at your physicians office. Payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or provider's office. You submitted documentation to the plan that includes a copy of an itemized bill. However, the record does not include proof of payment such as an itemized statement or receipt showing the bill was paid in full. We determined that the plan is not required to reimburse you for the vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Cyclobenzaprine Hydrochloride 10 milligram tablets. The Part D plan denied the request for coverage.  We received the case to perform 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 originally submitted to the plan indicates that Cyclobenzaprine Hydrochloride has been prescribed to treat restless leg syndrome. However, the Medicare approved compendia do not contain any citations to support the use of Cyclobenzaprine Hydrochloride for the treatment of restless leg syndrome.At reconsideration, the prescriber has requested to change the diagnosis to muscle cramps and back pain. However, no medical records have been submitted to validate the change in diagnosis. Furthermore, the Medicare approved compendia do not contain any citations to support the use of Cyclobenzaprine Hydrochloride for the treatment muscle cramps or back pain.Therefore, the documentation supports that the medication is not being prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the plan is not required to cover the Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Trelegy Ellipta 100-62.5 microgram inhalation prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because Trelegy Ellipta 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 plan shows Trelegy Ellipta 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: Unfavorable

At issue is coverage for Amphetamine-Dextroamphetamine 20 milligram tablets. The Part D plan denied the request for coverage.  We received the case to perform 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 indicates that Amphetamine-Dextroamphetamine has been prescribed for obstructive sleep apnea and idiopathic hypersomnia.  However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover Amphetamine-Dextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Savella 25 milligram tablets prescribed for fibromyalgia. The Part D plan denied your request for a tiering exception because Savella 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 plan shows Savella 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: Unfavorable

At issue is Rinvoq ER 15 milligram tablets prescribed daily for rheumatoid arthritis with rheumatoid factor, unspecified. The Part D plan denied your request for a tier change request because Rinvoq ER is in the specialty tier of your list of covered 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. The plan shows Rinvoq ER is a brand name Tier 5 drug. Your plan does not allow you to receive drugs in this tier at a lower cost share.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Eliquis 5 milligram tablets prescribed for chronic atrial fibrillation. The Part D plan denied your request for a tiering exception because Eliquis 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 plan shows Eliquis 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: Unfavorable

You requested Dupixent 300 milligram/2 milliliter pen injector prescribed as directed for severe bibasilar bronchiectasis, interstitial lung disease, asthma, chronic rhinosinusitis, and chronic hypoxemic respiratory failure. The Part D plan denied your request because the documentation did not support an off-formulary 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.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron 4 milligram tablet prescribed for unknown diagnosis. The Part D plan denied your request.We received the 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 plan submitted documentation that shows you were in the initial coverage stage of the Part D benefit when this drug was purchased. The plans Evidence of Coverage indicates 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. The record shows the plan paid its share of the cost for the Ondansetron and the remaining amount was your copay for a tier 1 drug filled at a long term care pharmacy. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Restasis 0.05 percent drops prescribed for keratoconjunctivitis sicca. The Part D plan denied your request for a tiering exception because Restasis 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 plan shows Restasis 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: Unfavorable

At issue is Hizentra 8-grams/5-milliliters Vial. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Trelegy Ellipta 100-62.5 milligram blister, with inhalation device prescribed for chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception because Trelegy Ellipta 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 plan shows Trelegy Ellipta 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

At issue is a request for coverage of Sildenafil 20 milligram tablets. The Part D plan denied the request for coverage.  We received the case to perform 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 indicates that Sildenafil has been prescribed for the treatment of secondary Raynauds syndrome due to systemic sclerosis.  The submitted medical records show that the enrollee has systemic sclerosis and severe Raynaud's symptoms with digit ulcers. The Medicare approved compendium, DrugDex, contains a citation for an acceptable off-label use of Sildenafil in the treatment of secondary Raynaud's phenomenon. It is noted that in a systematic review and meta-analysis of 244 patients with secondary Raynaud phenomenon, mostly related to systemic sclerosis, phosphdiesterase-5 inhibitors, including Sildenafil, moderately decreased mean Raynaud's Condition Score, daily frequency of Raynaud attacks, and duration of attacks. Therefore, the documentation supports that the medication is being used for a medically accepted indication and is eligible for coverage under Medicare Part D. Additionally, since the plans prior authorization criteria only addresses coverage of Sildenafil for enrollees who are being treated for pulmonary artery hypertension, an exception to the plans coverage criteria is medically necessary for this enrollee. A physician reviewed the appeal and determined that the plan is required to cover Sildenafil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Austedo 6 milligram tablets prescribed for chorea associated with cerebellar ataxia. 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 records show you prescribed Austedo 6 milligram tablets to treat the enrollees chorea associated with cerebellar ataxia. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Austedo 6 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sunosi 75 milligram tablet to treat hypersomnia in an enrollee with obstructive sleep apnea.   The requested drug is not on the plans formulary.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met
Appeal type: Prescription Drug
Decision: Unfavorable

At issue coverage for Vascepa 1 gram capsules prescribed for the treatment coronary artery disease and hyperlipidemia. The Part D plan denied the request for coverage.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 submitted medical records do not support that all of the plans requirements for coverage of this medication have been met. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage..