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

At issue is Vimpat 200 milligrams prescribed for seizures. The Part D plan denied your request for a tier change request because Vimpat 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 record shows Vimpat is being prescribed for seizures. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Vimpat 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 Butalbital/Aspirin/Caffeine/Codeine 50 milligram/325 milligram/40 milligram/30 milligram capsules prescribed for migraine headaches with aura. 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 Butalbital/Aspirin/Caffeine/Codeine capsules for migraine headaches with aura. 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

At issue is Abelcet 5 milligram/milliliter vial prescribed weekly to treat aspergillosis. 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. Abelcet is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hyoscyamine Sulfate 0.125 milligram tablets prescribed for stomach pain/constipation. The Part D plan denied your request because the drug at issue was not Food and Drug Administration approved. 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 record shows your physician prescribed Hyoscyamine Sulfate for stomach pain/constipation. The drug at issue is not Food and Drug Administration approved. Therefore, the drug cannot be considered a Part D benefit.We determined that the plan is not required to cover the Hyoscyamine Sulfate.
Appeal type: Prescription Drug
Decision: Favorable

You requested Rubraca 200 milligram tablets prescribed four times daily for metastatic endocervical carcinoma of GI subtype. 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 you have a diagnosis of metastatic endocervical carcinoma of GI subtype. You were initially diagnosed in 2018 with stage II disease and underwent chemotherapy/radiation. You were found to have multiple mutations and loss of heterozygosity. You are not a candidate for immunotherapy or chemotherapy due to recent hospitalization, infection, and stent placement. You cannot tolerate aggressive treatment. The drug at issue demonstrated progression free survival in maintenance for ovarian cancer patients who were BRCA mutated. The Medicare approved compendia contain citations to support this is a medically accepted indication. A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for a Potassium Citrate Extended Release 15 milliequivalent tablets. The Part D plan denied the request. We received a standard reconsideration request from the plan. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The information provided does not include a diagnosis or a receipt for Potassium Citrate. It was unable to be determined if the drug is medically indicated for the enrollees condition and amount paid by the enrollee. The requirements for reimbursement were not met. A physician reviewed your appeal and determined that the plan is not required to reimburse you for the Potassium Citrate tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 3% gel to treat osteoarthritis,  chronic low back pain, bilateral knee pain.  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 Neulasta 6 milligram injections prescribed for neutropenia, unspecified. 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. 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 indicate this drug is for patients on anti-cancer drugs with a clinically significant incidence of febrile neutropenia. However, the enrollee is on an anti-cancer drug with low incidences of febrile neutropenia. A physician reviewed your appeal and determined that the plan is not required to cover Neulasta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Muse intraurethral suppository 1000 micrograms to treat erectile dysfunction.   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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not FDA approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sumatriptan 20 milligram nasal spray prescribed for migraine headaches. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. The supporting statement did not indicate all formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Sumatriptan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gamunex-C 10 grams per 100 milliliter intravenous solution prescribed for the treatment of chronic inflammatory demyelinating polyneuropathy (variant: chronic immune sensory polyradiculopathy). 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. 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 submitted documentation does not satisfy the plans coverage criteria. The prescriber has addressed the prior authorization criteria, and the responses do not satisfy 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: Favorable

At issue is capsules to treat psoriatic arthritis. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The 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 Entresto 97-103 milligram tablets prescribed twice daily for chronic heart failure. 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 a supporting statement and medical records. We received the documentation and included it in our review.The record shows the doctor prescribed Entresto for an enrollee with chronic heart failure, New York Heart Association Class II. The Medicare approved compendia do support the use of this drug for the enrollees condition. The documentation submitted on March 5, 2021, shows that the enrollee does not have a history of angioedema related to previous angiotensin-converting-enzyme inhibitor or angiotensin II receptor blocker therapy. The documentation does not show that the enrollee is using Entresto within 36 hours of taking angiotensin-converting-enzyme inhibitors. Also, the documentation does not show that the enrollee is diabetic and using Entresto at the same time as Aliskiren. The documentation shows the enrollee has satisfied the plans coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Entresto.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Potassium chloride administered to you in the hospital for an unknown diagnosis. The plan denied your request for coverage because repackaged drugs are not covered under your Part D benefit. 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 record shows you were administered an individual dose of Potassium chloride while in the hospital. The submitted documentation provides a National Drug Code for the repackaged Potassium chloride of 60687-0341-44. According to the Food and Drug Administration, the code is not valid. Therefore, we determined the plan is not required to cover the Potassium chloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig Solution Auto-Injector 140 milligram/milliliter to treat migraines. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The prescriber has not submitted documentation of 3 months treatment with the drug and reduction in migraine days per month or that the patient experienced an inadequate treatment response with a 4 week trial of one of the following: Antiepileptic drugs, Beta-adrenergic blocking agents, Antidepressants, or the patient experienced an intolerance or has a contraindication that would prohibit a 4 week trial of any of the following: Antiepileptic drugs, Beta-adrenergic blocking agents, Antidepressants.  The documentation provided does not show the prior authorization criteria have been satisfied.A physician reviewed your appeal and determined that the plan is not required to cover Aimovig.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate 0.083% to treat respiratory distress syndrome. The Part D denied the request. We received a reconsideration request from the plan. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia does not support the use of this medication for the diagnosis submitted. Therefore, it is ineligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover Albuterol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 120 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for a lower cost-sharing tier. 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.Latuda is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier are 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 Tadalafil 2.5 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue was covered as a formulary exception and was not eligible 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.Tadalafil is a non-formulary brand drug. Non-formulary drugs are 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 Trelegy Ellipta Powder prescribed to treat chronic obstructive pulmonary disease. The Part D plan denied the request for a tiering exception. We received a standard 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. Trelegy Ellipta is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.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 Stiolto Respimat Aerosol 2.5 micrograms prescribed for to treat chronic obstructive pulmonary disease. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The records do not show why 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 Stiolto Respimat Aerosol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Edarbi 80 milligram tablet to treat hypertension. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Edarbi is a brand drug on Tier 4 of the plans formulary. Your doctor did not submit a supporting statement to indicate all brand alternatives on lower cost-sharing tiers had been tried. A request was submitted for a supporting statement. No documentation was received from your doctor. All brand 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

At issue is Xarelto 20 milligram oral tablet. The Part D plan denied your request for a tiering exception. We received an expedited auto-forwarded reconsideration request from the coverage level. 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.Xarelto 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

You requested Cyclobenzaprine HCL 10 milligrams prescribed as directed for radiculopathy of the lumbar region. The Part D plan denied the request because it 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. The record shows you were prescribed Cyclobenzaprine HCL to treat your condition. 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 the Cyclobenzaprine HCL because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trulance to treat the enrollees irritable bowel syndrome with constipation. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Propafenone Hydrochloride Extended Release 325 milligram tablets prescribed for paroxysmal atrial fibrillation. 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 levelPropafenone Hydrochloride is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why the all alternative medications 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: Favorable

You requested Lantus subcutaneous injection prescribed for you while inpatient in the hospital. The Part D plan denied your request for coverage under Medicare Part D because the National Drug Code for Lantus was either not provided or for a discontinued drug. 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 information submitted at the reconsideration level.The record shows the hospital submitted Lantus with National Drug Code 99245-0048-93 for payment to your plan, which was an invalid code. However, documentation submitted by you shows National Drug Code 00088-2220-33 for Lantus is a valid code listed with the Food and Drug Administration. Therefore, we determined the plan is required to cover the Lantus.