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

You requested Donepezil hydrochloride 5 milligram tablets prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows you received Donepezil hydrochloride from a preferred pharmacy. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that you paid for the Donepezil hydrochloride was not provided. Therefore, we determined that the plan is not required to reimburse you without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sutab 1479/225/188 milligram tablets prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows you received Sutab from a preferred pharmacy. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that you paid for the Sutab was not provided. Therefore, we determined that the plan is not required to reimburse you without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clotrimazole-betamethasone 1%-.05% cream prescribed for unknown diagnosis. The Part D plan denied your request.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 when this drug was purchased. The plans Evidence of Coverage indicates reimbursement is calculated 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 Clotrimazole-betamethasone cream and the remaining amount was your copay for a tier 2 drug filled at a network pharmacy. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cefuroxime 500 milligram tablets prescribed for unknown diagnosis. The Part D plan denied your request.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 when this drug was purchased. The plans Evidence of Coverage indicates reimbursement is calculated 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 Cefuroxime and the remaining amount was your copay for a tier 2 drug filled at a network pharmacy. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix 50 microgram/0.5 vial kit prescribed for shingles vaccination. The Part D plan denied your request.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 when this drug was purchased. The plans Evidence of Coverage indicates reimbursement is calculated 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 Shingrix and the remaining amount was your copay filled at a network pharmacy. 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 Spravato 56 milligram solution prescribed 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. The records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. The prescriber has not provided patient specific clinical rationale, with supporting medical documentation, to indicate that all alternatives required by the plan have been tried and failed, or why the plans preferred drugs would likely not be as effective as the requested drug.  A physician reviewed your appeal and determined that the plan is not required to cover Spravato.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Stelara 45 milligram/0.5 milliliter pre filled syringe to treat the enrollees condition.   The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Morphine Sulfate Extended Release 30 milligram tablets to treat pain. 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. In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, medical records are required. These records were requested from the prescriber and we did not receive medical records that could answer the medical necessity issues. 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 Morphine Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Onglyza 5 milligram tablet prescribed to treat diabetes. 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.Onglyza 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 Potassium chloride 10 milliequivalent tablets prescribed for unknown diagnosis. The Part D plan denied your request.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 when this drug was purchased. The plans Evidence of Coverage indicates reimbursement is calculated 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 tablets and the remaining amount was your copay for a tier 1 drug filled at a network pharmacy. 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 Hetlioz 20 milligram capsule to treat non-24 hour sleep-wake disorder. The Part D plan denied the 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. The prescriber was asked to provide medical records.  No medical records were provided by the prescriber to support a diagnosis of totally blind. 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 Dexcom G6 Continuous Glucose Monitoring (CGM) system prescribed for diabetes. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Supplies for testing and monitoring blood glucose levels are not considered Part D drugs and may be covered under the Medicare Part B Durable Medical Equipment benefit.A physician reviewed your appeal and determined that the requested diabetic equipment is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You asked for reimbursement for a Shingrix Kit 50 microgram/0.5. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The information provided supports all requirements have been met for reimbursement of a Shingrix injection. A receipt has been submitted for the amount of $201.60. A physician reviewed your appeal and determined that the plan is required to reimburse the amount of the Shingrix injection.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrochlorothiazide 25 milligram tablets prescribed for unknown diagnosis. The Part D plan denied your request.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 when this drug was purchased. The plans Evidence of Coverage indicates reimbursement is calculated 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 Hydrochlorothiazide and the remaining amount was your copay for a tier 1 drug filled at a network pharmacy. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Advair Diskus 500/50 microgram oral inhaler prescribed for obstructive lung disease. The Part D plan denied your request for a tiering exception because Advair Diskus is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative 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. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Advair Diskus is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha SureClick 140 milligrams per milliliter solution auto-injector to treat the enrollees condition. The Part D plan denied your request for a formulary 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 level.Repatha SureClick is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Repatha SureClick.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nucala 100 milligram/milliliter auto-injector prescribed as directed for uncontrollable asthma with an elevated eosinophil count. 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 also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated why alternatives required by the plan, such as Fasenra would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Nucala.A physician reviewed your appeal and determined that the plan is not required to cover the Nucala.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligrams per milliliter to treat age related osteoporosis. The Part D plan did not make a decision.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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.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: Unfavorable

At issue is Hetlioz 20 milligram capsules to treat non-24-hour sleep wake 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. A request was submitted to the prescriber to address the prior authorization criteria, and to provide supporting medical records. A reply from the prescriber was not received. Therefore, the plans coverage criteria are not satisfied. 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 Omnipod Dash 5-pack pods to treat Type 2 diabetes mellitus. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 Lidocaine 5% patch prescribed as directed for a contracture of an unspecified joint. The Part D plan denied the 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. The prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the plans prior authorization criteria. We received a response and have included it in our review. The medical records show your doctor prescribed the Lidocaine patch to treat your condition. Your physician sent answers to the prior authorization questions. However, no medical records were provided by the prescriber. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Cyclobenzaprine Hydrochloride 10 milligram tablets. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Cyclobenzaprine Hydrochloride has been prescribed for the management of muscle spasms of the back due to chronic conditions. However, the Medicare approved compendia do not contain any citations to support the use of Cyclobenzaprine Hydrochloride for the treatment of muscle spasms related to chronic conditions. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligram tablets to treat the diagnosis of moderate to severe psoriasis. 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.Otezla 30 milligram tablet is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Otezla 30 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xyosted 75 milligram/0.5 milliliter auto injector for the enrollees condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.This drug is being provided by the plan 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

You requested Eliquis 5 milligram prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows you purchased Eliquis from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated 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 plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.