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

At issue is Eliquis 5 milligram tablets prescribed twice daily for atrial fibrillation. The Part D plan denied your request for a tiering exception because there were no other brand drugs at a lower tier. 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.Eliquis is a brand drug on Tier 3 of the plans formulary. There are no lower tier brand drugs of the same type on the Plan's formulary to treat the enrollee's 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 cover Eliquis at a lower cost-sharing tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Advair Diskus 500/50 microgram for chronic obstructive pulmonary disease. You asked the Part D plan to provide a tiering exception. Your plan denied the request because the drug you are taking was not eligible for tier cost sharing exception. Advair is a brand drug on Tier 3 drug of your plan. Your plan does not lower the cost sharing amount for drugs in this tier. Therefore, Advair was excluded from a copay reduction.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The records show Advair is being prescribed for chronic obstructive pulmonary disease. The Medicare approved compendium, supports the use of the requested drug for your condition. Advair is a brand name drug on Tier 3 of your plan's formulary. There are no lower tier brand name drugs of the same type on the lower cost sharing tiers. Therefore, the requested drug is not eligible for a tiering cost sharing exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent ointment prescribed as needed for your condition. The Part D plan denied coverage because medical necessity was not established. 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. We also researched Medicare systems and reviewed the enrollment data available.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We also requested documentation to show that you met the prior authorization requirements. We did not receive the documentation requested.The documentation submitted does not include medical records to show your doctor prescribed Lidocaine 5 percent ointment for a medically accepted indication. Additionally, the records do not include documentation from your prescriber to show you met the prior authorization requirements.   The plan requires prior authorization criteria for the Lidocaine 5 percent ointment to be met  before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5 percent ointment because the plan requires prior authorization before covering some prescription drugs.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gralise 300 milligrams prescribed for flushing and malignant neoplasms of overlapping sites of left female breast. The Part D plan denied your 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Gralise 300 milligrams to treat your flushing and malignant neoplasms of overlapping sites of left female breast. 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 300 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Horizant 600 milligram tablets prescribed as directed. The Part D plan denied your request for a tiering exception because the drug you requested is not included on the plans formulary. 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.Horizant is a brand drug, which is not included on the plans formulary. The plan agreed to cover the drug, but requires you to pay cost sharing at the non-formulary/non-preferred copay level. Therefore, this non-formulary drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Horizant.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron 8 milligrams prescribed as needed for nausea and vomiting. The Part D plan denied your request because it 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 Ondansetron 8 milligrams as needed to treat your nausea and vomiting secondary to gastritis, as documented in the medical records. 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 Ondansetron 8 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Toviaz 4 milligrams prescribed daily for urinary frequency. 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. Toviaz 4 milligrams is a brand drug on Tier 4 of the plans formulary. The prescriber statement shows you were prescribed Toviaz 4 milligrams for urinary frequency. 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 cover Toviaz 4 milligrams because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Inveltys 1% eye drops prescribed for post cataract surgery. The Part D plan denied your request for reimbursement because you used a coupon card when paying for your eye drops. 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 record shows the Inveltys discount was applied to the purchase because your insurance information was not up-to-date or not available. According to the Inveltys website (https://Inveltys.com), the discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the Inveltys discount, you acknowledged and agreed that Inveltys will be treated as the primary payor with respect to the medications that you have selected to purchase through the Inveltys discount program. Therefore, the plan is not required to cover or provide reimbursement for Inveltys 1% eye drops. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance, without applying the Inveltys discount.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Topiramate 50 milligrams prescribed twice daily for autism spectrum disorder. The Part D plan denied your request because it 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 Topiramate 50 milligrams twice daily to treat your autism spectrum disorder. 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 Topiramate 50 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy, 100 mg tablet, prescribed daily for chronic migraine headache without aura. 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 also researched Medicare systems and reviewed the enrollment data available.Your physician submitted a supporting statement and medical records. The medical records show the physician had prescribed Ubrelvy to treat your chronic migraine headaches. The Medicare approved compendia support the use of this drug to treat your condition. The medical records show that you tried Botox, amitriptyline, gabapentin, sumatripan, and propranolol. These drugs did not improve your condition. However, the plan formulary includes other drugs that could be used to treat your condition. Your medical records do not show that all alternative drugs on the plan's formulary have been tried and failed, been ineffective , or would be contraindicated.The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit. A physician reviewed your appeal and determined that the plan is not required to cover an off-formulary exception for Ubrelvy. The decision of the QIC is unfavorable.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xospata 40 milligram tablets prescribed three times daily for acute myeloid leukemia. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. 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. Xospata is a brand drug on Tier 5, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the specialty tier from the tiering exception process. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Xospata. A tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Butalbital/acetaminophen/caffeine 50 milligrams/325 milligrams/40 milligrams tablets prescribed every six hours as needed for chronic intractable headaches. The Part D plan stated this drug is covered at the cost-sharing tier listed in your 2021 Drug Guide. The Part D plan denied your request for a tiering exception because the documentation did not explain why alternative drugs in a lower tier would not work just as well. 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. Butalbital/acetaminophen/caffeine is a generic drug on Tier 4 of the plans formulary. The prescriber statement shows you experienced allergic reactions to Ibuprofen and Elavil. The prescriber statement also shows that you experienced side effects with the use of Aspirin. In addition, the prescriber statement states that Imitrex, Tylenol, Excedrin Migraine, and Prednisone did not work for you. However, there are no generic 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 cover Butalbital/acetaminophen/caffeine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcipotriene 0.005% cream prescribed daily for Grovers Disease. The Part D plan denied your request because ENTER DENIAL REASON. We received an expedited 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.Your medical records show Calcipotriene cream was prescribed to treat Grovers Disease. However, the Medicare approved compendia do not support the use of this drug for your condition. The physician progress note submitted indicates the enrollee has conditions including seborrheic dermatitis, dermatographic urticaria, and transient acantholytic dermatosis. However, the medical record does not include a medically accepted indication for the drug at issue. A physician reviewed your appeal and determined that the plan is not required to cover Calcipotriene 0.005% cream.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Jardiance, 25 milligrams, half tablet prescribed every morning for diabetes mellitus. You asked the Part D plan to provide a tiering exception. Your plan approved the use of the brand named drug Jardiance for your condition. Your plan does not include other brand name drugs on the lower cost-sharing tiers to treat your condition. As such, your drug was excluded from a cost-sharing tier exception. 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. We also researched Medicare systems and reviewed the enrollment data available.The records show Jardiance is being prescribed for diabetes mellitus. A Medicare approved compendium supports the use of the requested drug for your condition. Jardiance is a brand name drug on Tier 3 of your plan's formulary. There are no brand name drugs of the same type on the lower cost-sharing tiers to treat your condition. Therefore, the requested drug is not eligible for a cost-sharing tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent ointment prescribed as needed for osteoarthritis of the cervical spine. The Part D plan denied your request because it 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 Lidocaine 5 percent ointment as needed to treat your osteoarthritis of the cervical spine. 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 Lidocaine 5 percent ointment because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Invega Sustenna 234 milligram per 1.5 milliters prescribed every 21 days for your sons diagnosis of schizophrenia. The Part D plan denied your request because the drug at issue exceeded the plans quantity restrictions. We received your 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 medical records show that on November 2, 2020, the doctor prescribed Invega Sustenna 234 milligrams per 1.5 milliters every three weeks to treat your sons condition. However, the Food and Drug Administrations label does not list the requested frequency of every three weeks for Invega Sustenna. In addition, the medical record fails to support the medical reason for the dose frequency of every three weeks.A physician reviewed your appeal and determined that the plan is not required to cover Invega Sustenna, per Food and Drug Administrations label criteria.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 250 milligram tablets prescribed for hypersomnia. The Part D plan denied your request because the drug was prescribed for a non-medically accepted indication. 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.Your medical records show your doctor prescribed Armodafinil for your diagnosis of hypersomnia. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligrams prescribed daily for circadian rhythm sleep disorder, free running type. The Part D plan denied coverage because medical necessity was not established. 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 your doctor prescribed Hetlioz 20 milligrams daily for circadian rhythm sleep disorder, free running type. The Medicare approved compendia supports the use of this drug to treat your condition. However, 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 enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover the Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligrams prescribed daily for circadian rhythm sleep disorder, free running type. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication, and because medical necessity was not established. 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Hetlioz 20 milligrams daily to treat your circadian rhythm sleep disorder, free running type. The Medicare approved compendia support the use of this drug to treat your condition. However, the plan requires prior authorization criteria for this drug to be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz 20 milligrams because the plan requires prior authorization before covering some prescription drugs.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 20-10 milligrams prescribed twice daily for pseudobulbar affect. The Part D plan denied your request because it 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 Nuedexta 20-10 milligrams twice daily to treat your pseudobulbar affect. The Medicare approved compendia support the use of this drug for your condition. However, the plans prior authorization criteria for this drug have not been satisfied. Therefore, the drug cannot be considered for payment by the plan.A physician reviewed your appeal and determined that the plan is not required to cover Nuedexta 20-10 milligrams.