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

At issue is Vascepa 1 gram capsules. 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 levelVascepa is a brand drug on Tier 4 of the plans formulary. There are no brand name drugs in the lower cost-sharing tier to treat your condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tdvax Suspension 0.5 milliliter intramuscular prescribed after your injury. 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 received an expedited 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. 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

At issue is Eliquis 5 milligram oral tablet. 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.Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tymlos 80 microgram dose pen injector to treat your condition. 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 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 is Sensipar 60 milligram tablets. The Part D plan denied coverage because there was insufficient documentation to determine if the medication was eligible for coverage under Medicare Part D. 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. A prescriber statement and medical records were requested from the prescribing physician during this review, but not received.The documentation indicates that the Sensipar is being prescribed to treat the enrollees anemia and vitamin D deficiency secondary to chronic kidney disease on dialysis. While the Medicare approved compendia include secondary hyperparathyroidism in adults with chronic kidney disease on dialysis as an acceptable indication for the use Sensipar, there are no medical records to validate the presence of hyperparathyroidism. Therefore, it is not possible to determine if the medication is being prescribed for a medically accepted indication. 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 Potassium Chloride Packet 20 milliequivalent to treat hypokalemia. 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 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. The extended release tablets on the formulary cannot be crushed, however, there are over-the-counter liquid and powder forms of potassium chloride. 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 Myrbetriq ER 25 milligram tablets. The Part D plan denied your request for a tiering exception. 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. Myrbetriq ER is a brand drug on Tier 3 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 the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xiidra 5% eye drops to treat dry eye syndrome.  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 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 is Flector Patch 1.3% prescribed to treat acute pain due to trauma. The Part D plan denied your request for a formulary and 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. We also researched Medicare regulations and Medicare approved compendia. The drug requested is not on the plans formulary. There are no medical records supporting that all alternative drugs on the plans formulary, to treat the same condition, have been tried. Additionally, tiering exceptions cannot be made on non-formulary drugs. A physician reviewed your appeal and determined that the plan is not required to cover Flector Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clindamycin phosphate 1% gel prescribed as directed for granulomatous folliculitis. 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 Clindamycin phosphate gel for the treatment of granulomatous folliculitis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Clindamycin phosphate gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Benzonatate 200 milligram capsules 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 determined that the plan is not required to cover Benzonatate. Drugs prescribed for symptomatic relief of cough and colds 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 payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vancomycin HCL 125 milligram tablets prescribed daily for primary sclerosing cholangitis. The Part D plan denied your request because the provided diagnosis does not meet the criteria of 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor Vancomycin HCL 125 milligram tablets to treat your primary sclerosing cholangitis. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.  A physician reviewed your appeal and determined  that the plan is not required to cover Vancomycin HCL because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 60 milligrams to treat attention deficit hyperactivity disorder. 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 reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.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 Shingrix 50 microgram/0.5 milliliter vial kit prescribed for shingles vaccination. The Part D plan denied your request for a lower cost level for the brand Shringrix because there are no lower cost brand name drugs on your plans formulary. We received a request to reconsider the appeal. 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.The plan submitted documentation that shows coverage was allowed for the 1st dose of Shingrix injection, which you received at the pharmacy on November 24, 2020, and your copay was $20. The record shows you returned to pharmacy on January 27, 2021 to receive your 2nd dose of the Shingrix, but your request was denied because not enough time had passed since you had received your Covid vaccine. The pharmacy mistakenly filed a claim for date of service January 27, 2021 and was paid. You returned on February 22, 2021 to receive your 2nd dose. According to your plans Evidence of Coverage for 2021, your copay amount is $75 for a tier 4 drug. 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. We have determined the plan was correct in calculating your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Diclofenac Sodium 1 percent topical cream prescribed daily for trochanteric bursitis of right hip. 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 Diclofenac Sodium for trochanteric bursitis of right hip.In review of the Medicare approved compendium, trochanteric bursitis of right hip is not a medically accepted indication for Diclofenac Sodium. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Diclofenac Sodium at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Pregabalin 50 milligram capsules prescribed for neuropathy, back pain with radiculopathy, and chronic 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 Pregabalin for neuropathy, back pain with radiculopathy, and chronic pain.In review of the Medicare approved compendium, neuropathy, back pain with radiculopathy, and chronic pain are not medically accepted indications for Pregabalin. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover Pregabalin at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gralise ER 600 milligram tablets prescribed daily for spinal stenosis, lumbosacral region. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received a reconsideration request.  We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Gralise to treat your spinal stenosis. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.  A physician reviewed your appeal and determined  that the plan is not required to cover Gralise because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Remicade. 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 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. 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

At issue is Lidocaine 5% patches. The Part D plan denied coverage stating that the plans prior authorization requirements were not met.  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 the Lidocaine has been prescribed the treatment of right-sided chronic low back pain with sciatica. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. Since the drug is not available for coverage under Medicare Part D, the plans prior authorization requirements are not applicable to this case.A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xhance to treat chronic sinusitis. 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: Unfavorable

At issue is Promethazine Hydrochloride 25 milligram tablets to treat nausea as a symptom of diverticulitis. The Part D plan denied coverage because medical necessity was not established for this off-label use. 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: Unfavorable

At issue is Stiolto Respimat 2.5-2.5 micrograms per actuation, oral inhalation to treat the diagnosis of chronic obstructive pulmonary 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.Stiolto Respimat is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain 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.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 a tiering exception request for Humira 40 milligram per 0.4 milliliter pen 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 at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Femring to treat your condition. 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 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 is Haegarda 2000 unit vial to treat hereditary angioedema Type 3. The Part D plan denied the request stating the Medicare's drug reference books (compendia) do not support using this drug to treat prophylactic treatment of hereditary angioedema type 3. 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.