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

At issue is Aimovig 140 milligrams/milliliter injection prescribed once monthly to treat your condition. 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. The records show Aimovig 140 milligrams/milliliter injection is a brand biologic on Tier 4 of the plans formulary. We requested a prescriber statement to support your condition and all other alternatives you have tried. However, we have not received a prescriber statement. In addition, there are no brand biologics of the same type on the lower cost sharing tiers. Therefore, this biologic is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Aimovig 140 milligrams/milliliter injection at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% ointment to be applied as directed for post-herpetic polyneuropathy. The Part D plan denied the drug because it was not medically necessary. The plan requires prior approval before covering some drugs. If prior approval is not obtained, the plan may not cover the drug. 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 records submitted at the reconsideration level.Lidocaine 5% ointment is being requested to treat the enrollees condition. The Medicare approved compendia do not support the use of this ointment for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Verapamil ER PM 300 milligram capsule prescribed three times daily 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.Verapamil ER PM 300 milligram capsule is a generic drug on Tier 1 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone HCL ER 80 milligrams tablet prescribed for low back pain and impingement syndrome. The Part D plan denied your request due to available formulary alternatives and was auto-forwarded due to untimely notification. 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 physician submitted a supporting statement. The prescriber statement shows the physician had prescribed Oxycodone HCL ER to treat low back pain and impingement syndrome. However, the records do not show why preferred alternatives on the plans formulary for the same condition have not been tried. Specifically, the documentation does not show that the enrollee has tried all formulary alternatives, or why the enrollee cannot take them.A physician reviewed your appeal and determined that the plan is not required to grant a non-formulary exception for the Oxycodone HCL ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sunosi tablet, 75 milligrams was prescribed to treat insomnia related to anoxic encephalopathy due to cardiac arrest. The Part D plan denied the request because off-formulary exception criteria were not met. 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 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 your 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 Nexlizet 180 milligram/10 milligram tablets prescribed for hyperlipidemia. 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. We requested a supporting statement from your doctor. We did not receive a supporting statement to support formulary alternatives were tried and failed. Therefore, 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 Nexlizet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement of payment for Omnipod Dash Cartridge 5 pack pods prescribed for type two diabetes mellitus. The Part D plan denied the request. 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. We also researched Medicare systems and reviewed the enrollment data available.The plan requires certain prior authorization guidelines be met before approving this request. The prescriber was sent a request for information as to why you require the Omnipod and for records supporting multiple daily injections and oral agents were tried and failed. No documentation was received. The documentation provided does not show that you have satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover the Omnipod Dash Cartridge 5 pack pods.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Keppra 1000 milligram tablets prescribed twice daily 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.Keppra is a non-formulary brand drug. Non-formulary drugs are covered by the plan on Tier 5 and 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 Xarelto 15 milligram tablet prescribed for atrial fibrillation. This case was auto-forwarded by the plan. 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. 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 your request for a tiering exception. There is no brand drug on a lower eligible tier of the same type that is used to treat your condition. Therefore, your plan is not required to offer you a lower cost share.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Anoro Ellipta (Umeclidinium Bromide/Vilanterol Trifenatate), 62.5 micrograms/25 micrograms/actuation inhaler, Tier 3, prescribed for chronic obstructive pulmonary disease. You asked the Part D plan to provide a cost-sharing tiering exception. The plan denied the appeal because there are no brand name drugs in the lower cost-sharing tiers that treat your condition. 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 Anoro Ellipta is being prescribed for your chronic obstructive pulmonary disease. A Medicare approved compendium supports the use of the requested drug for your condition. Anoro Ellipta is a preferred brand name drug on Tier 3 of your plan's formulary. There are no brand name drugs of the same type in the lower cost-sharing tiers. Therefore, the requested drug is not eligible for a cost-sharing tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Anoro Ellipta because the preferred brand name drug is not eligible for a cost-sharing tiering exception, as there are no brand name drugs of the same type in the lower cost-sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Plaquenil 200 milligram tablets. This case was auto-forwarded by the plan. 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 requested information from your doctor. Your doctor did not provide your condition or why you cannot take other drugs on your plans formulary or your condition. A physician reviewed your appeal and determined that the plan is not required to cover Plaquenil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac 35 milligram capsules prescribed for rheumatoid arthritis. The Part D plan denied the request because the manufacturer of the drug at issue did not participate in the Medicare Gap Discount Program. We received a request from the appellant to reconsider the appeal. 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 the manufacturer of the drug at issue, Trivue Pharmaceutical, does not participate in the Medicare Gap Discount Program. Payment cannot be allowed for a drug whose manufacturer does not participate in the Medicare Gap Discount Program.We determined that the plan is not required to cover the drug at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 49/51 milligram tablets prescribed twice daily for chronic systolic heart failure. The Part D plan denied your request for a tiering 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. Entresto 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 your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle libre 14 day sensor prescribed by your doctor for type 2 diabetes mellitus. The Part D plan denied your request because this drug does not meet the definition of a Part D drug. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We determined that the plan is not required to Freestyle libre 14 day sensor because it is not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. 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 Humalog  100 unit/milliliter prescribed for diabetes. 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 auto-forwarded request from the plan to reconsider the appeal.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 Humalog is being administered through an infusion pump in the home for treatment of diabetes. Medicare law specifically excludes coverage for any drug for which payment would be available under Part A or Part B of Medicare for that individual. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Humalog. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vancomycin Hydrochloride 125 milligram tablets prescribed for the diagnosis of pouchitis. The Part D plan denied the request. We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We 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 Vancomycin Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Novolog 100 unit/milliliter vial  prescribed by your physician. 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 auto-forwarded request from the plan to reconsider the appeal.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 Novolog is being administered through an external infusion pump. Medicare law specifically excludes coverage for any drug for which payment would be available under Part A or Part B of Medicare for that individual. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Novolog. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80 milligram injection to treat her ankylosing spondylitis.  The Part D plan denied your request because the prior authorization criteria were not met. Specifically, the prescriber stated the enrollee had not had an inadequate response, intolerance, or contraindication to Enbrel or Humira. 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 enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria.  Namely, the prior authorization requires the enrollee to have tried Enbrel, Humira, Xeljanz and/or Xeljanz ER or have a contraindication. The prescriber stated there was a contraindication but did not state what it was. 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 Diclofenac epolamine patch 1.3% was prescribed to treat diabetic polyneuropathy. 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 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 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 Fenofibrate 160 milligrams prescribed for metabolic syndrome and recurrent pancreatitis. You requested that the plan provide a tiering exception. We received a 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. Fenofibrate 160 milligrams is a generic drug on Tier 3 of the plans formulary. The doctor submitted a supporting statement. The statement said the enrollee is stable on Fenofibrate. However, the plans formulary includes other medications, which are the same class as Fenofibrate, on lower tiers. The doctor did not address why all available drugs in the same class would not work for the enrollee. All generic drugs on lower tiers have not been tried. Therefore, this drug is not eligible for a tiering exception.  A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levemir solution. The Part D plan denied your request to cover this insulin at a lower tier cost. The plan indicated this is a select insulin and is already provided at a lower tier cost. 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 Levemir is on Tier 3 of the formularys plan; however, Levemir is considered a select insulin and 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 for the Levemir solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Azelastine HCl 0.1% nasal spray 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.Azelastine HCl 0.1% nasal spray is a generic drug on Tier 3 of the plans formulary. There are no generic 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

At issue is Privigen 10% ordered 2 grams per kilogram of ideal body weight to be given every four weeks for immune-mediated sensory neuropathy. The Part D plan denied the drug because it was not medically necessary. The plan requires prior approval before covering some drugs. If prior approval is not obtained, the plan may not cover the drug. 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 records submitted at the reconsideration level.Privigen 10% is being requested to treat immune-mediated sensory neuropathy. 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 the Privigen 10%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluoxetine 60 milligram tablets prescribed daily for major depressive disorder. 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. We requested a prescriber statement to support what formulary alternatives have been tried and why they have failed. We have not received a prescriber statement. 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 Fluoxetine 60 milligram tablets prescribed daily.