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

At issue is Fluorometholone 0.1% ophthalmic suspension prescribed for treatment status-post corneal transplant. The Part D Plan denied your request for a tiering exception because the drug is already on the lowest 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. Fluorometholone 0.1% ophthalmic suspension is an authorized generic drug on Tier 3 of the plans formulary. Authorized generics are considered branded drugs for tiering purposes. 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

At issue is a tiering exception request for Estradiol 0.01% cream 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.Estradiol 0.01% cream is a generic drug on Tier 4 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

At issue is Zolpidem tartrate 10 milligram tablet prescribed as directed for insomnia. The Part D plan denied coverage because 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 records submitted at the reconsideration level. Your medical records show you were prescribed Zolpidem tartrate for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has 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 the Zolpidem tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligram tablet to treat psoriatic arthritis. 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 Xifaxan 550 milligram tablets to treat the enrollees condition. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The 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. A physician reviewed your appeal and determined that the plan is not required to cover Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acyclovir 5% ointment to treat herpes viral vesicular dermatitis. The Part D plan denied the request. 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 asked you to send us a supporting statement to show why the Acyclovir 5% ointment is medically necessary. However, we did not receive the documentation.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Ibuprofen 600 milligram tablets prescribed for you in the hospital. The Part D plan approved coverage for the drug. We received an auto-forwarded request from the plan to reconsider the appeal. 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 received the drug under observation for medical care at the hospital. You submitted documentation to the plan that includes a copy of an itemized hospital bill. The documentation provided indicates the plan approved payment for the Ibuprofen. Therefore, we determined that the plan is required to reimburse you. 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 out-of-network pharmacy (i.e., hospital) charged you.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Zafirlukast 20 milligram oral tablet 180/90 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.Zafirlukast 20 milligram oral tablet is a generic drug on Tier 4 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

At issue is Testosterone Gel Pump 1.62% prescribed for low testosterone levels. The Part D plan denied the request. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The prescriber indicates that this is initial treatment. The documentation does not include two morning serum testosterone levels that are less than the reference range for the laboratory, taken at separate times, prior to treatment. Therefore, the prior authorization requirements were not met.   A physician reviewed your appeal and determined that the plan is not required to cover Testosterone Gel Pump.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 100 milligram tablets prescribed twice daily (180.90) for narcolepsy. The Part D plan denied your request for a quantity limit exception request. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates your doctor prescribed Modafinil 100 milligrams for narcolepsy. The documentation submitted does not address why you are not able to take a higher dosage daily. The drug at issue is available in 200 milligram doses. Your doctor requested 100 milligrams twice daily, which is greater than the plans quantity limit criteria. An exception to the quantity limit criteria was not met.Therefore, the plan is not required to cover Modafinil for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Repatha 140 milligrams per milliliter ordered for hyperlipidemia and atherosclerotic heart disease of native coronary artery without angina pectoris. The Part D plan denied the request because the records did not support why the preferred drug Praluent would not work just as well.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.A supporting statement and medical records were submitted. The records show Repatha was ordered to treat your condition. The Medicare approved compendium supports the use of the drug for this condition.The records show that you cannot take other drugs on the plans formulary for this condition. Specifically, Praluent caused extreme pain and swelling at the injection site and diffuse joint and muscle pain, flu symptoms, and coughing.A physician reviewed your appeal and determined that the plan is required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Loteprednol Etabonate 0.5% gel to treat the diagnosis of chronic corneal decompensation. 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 medical records show the requested drug is being prescribed to treat the enrollees condition. 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 the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your 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 Tresiba Flextouch Solution Pen Injector to treat the enrollees diabetes mellitus. 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.Tresiba 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. Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Symbicort 160/4.5 microgram tablets prescribed for unknown diagnosis. The Part D plan denied your request for additional reimbursement. We received an auto-forwarded request from the Plan to reconsider the appeal.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. The plan calculates reimbursement based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The record shows the plan paid its share of the cost for the Symbicort and the copay of $47 was charged to you. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Viibryd 20 milligram tablet to treat major depressive disorder. 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 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 Gabapentin Powder to treat pain. The Part D plan denied your request for this compounded Bulk powder drug because it is not Food and Drug Administration approved. 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 documentation shows that Gabapentin Powder is being used as a compounded bulk powder drug. Drugs compounded from bulk powders are not Food and Drug Administration approved; therefore, they are not covered under Part D. In conclusion, the decision of the QIC is unfavorable.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta 50 milligram tablets. 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. There was no diagnosis or medical records to determine if the drug is medically indicated for the enrollees condition.  A physician reviewed your appeal and determined that the plan is not required to cover Nucynta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Abiraterone 250 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 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.Abiraterone 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 Duloxetine 60 milligram tablets for a 90 day supply. The Part D plan denied the request for additional reimbursement. We received a request to reconsider the appeal.We conducted 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. No additional documentation was requested from the enrollee.The plan submitted documentation that shows you were still in the deductible stage for part of the cost for this drug and entered the initial stage for the remaining amount. You are responsible for the full cost of covered drugs until the deductible amount is satisfied. After the deductible was met, the plan calculated 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 determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 25 milligram tablets for a 30 day supply. The Part D plan denied the request for additional reimbursement. We received a request to reconsider the appeal.We conducted 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. No additional documentation was requested from the enrollee.The plan submitted documentation that shows you were still in the deductible stage for the drug at issue. You are responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined this drug was paid correctly and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium chloride 10 Milligram equivalent tablets for a 90 day supply. The Part D plan denied the request for additional reimbursement. We received a request to reconsider the appeal.We conducted 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. No additional documentation was requested from the enrollee.The plan submitted documentation that shows you were in the initial coverage stage of the Part D benefit. The plan calculates reimbursement based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The record shows the plan paid its share of the cost for the Potassium chloride and the remaining amount was charged to you. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tdap vaccine  prescribed and administered by your physician. The Part D plan denied the request for reimbursement. We received a request to reconsider the appeal. 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 received the 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 Natesto Gel Pump to treat decreased testosterone level(s). The Part D plan denied a request for this drug because you did not have a medically accepted indication. We received an expedited reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis/indication for this enrollee is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ingrezza Initiation Pack 40-80 milligrams prescribed for Tardive Dyskinesia. The Part D plan did not provide a timely 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 information submitted at the reconsideration level. The prescriber has not indicated 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 your appeal and determined that the plan is not required to grant your request for a formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tecfidera 240 milligram DR capsules prescribed for multiple sclerosis. 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 indicated you had tried the generic form of the drug at issue as well as a recent therapy with Glatiramer Acetate. However, there were no medical records submitted to support the information on the statement. The record does not support you have tried two alternative formulary drugs.A physician reviewed your appeal and determined that the plan is not required to cover Tecfidera.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Gel 20.25 milligram/1.25 grams to treat hypopituitarism and post procedural hypopituitarism. 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 do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees condition. The drug is not approved by the food and drug administration to treat the diagnoses submitted. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Testosterone Gel.