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

At issue is Diclofenac Sodium 1% gel to be applied four times a day for rheumatoid arthritis. 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 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 records submitted at the reconsideration level.Diclofenac Sodium 1% gel is being requested to treat rheumatoid arthritis and cervicalgia. The Medicare approved compendia do not support the use of this drug, as prescribed, for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover the Diclofenac Sodium 1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Procrit 10000 units/milliliter prescribed for the enrollees anemia in chronic kidney disease. 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. The documentation supports the drug was prescribed for the enrollees diagnosis of anemia in chronic kidney disease. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Aimovig 140 milligrams prescribed once a day for migraine prevention. 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. Your medical records show your doctor prescribed Aimovig for migraine prevention. Medicare approved compendia do support the use of this drug for your condition. However, 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 Aimovig.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine HCl 10 milligram tablets prescribed for the enrollees myalgia and sacroiliitis. 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 as an autoforwarded coverage determination.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 documentation supports the drug was prescribed for the enrollees diagnosis of myalgia and sacroiliitis. No medical records were provided. The use of the requested drug to treat the provided diagnoses 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 these conditions.  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

You requested Lidocaine 5 percent ointment to treat chronic pain. The Part D plan denied your request because the provided diagnosis 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. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the 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

At issue is Onglyza 2.5 milligrams prescribed as directed for type 2 diabetes. 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.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 step therapy criteria. We did not receive the documentation requested.The prescriber has not indicated that the enrollee has tried all alternatives required by the plan, or why the plans required step therapy drugs would likely not be as effective for the enrollee as the requested drug. Our Physician Reviewer's opinion is that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Hydroxychloroquine Sulfate 200 milligram tablets prescribed daily for arthritis. The Part D plan denied your request for a tiering exception because Hydroxychloroquine Sulfate is a generic Tier 3 drug and there are no other drugs on a lower tier to treat the same 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. The record shows Hydroxychloroquine Sulfate is being prescribed for arthritis. The Medicare approved compendium, supports the use of the requested drug for your condition. The plan shows Hydroxychloroquine Sulfate is a generic Tier 3 drug. There are no other drugs on a lower tier to treat the same condition.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligram/milliliter injection 90 day supply prescribed for unknown diagnosis. The plan provided coverage at a copay amount that was higher than you agreed to pay. Therefore, the claim was reversed and the prescription was not filled. We received an auto-forwarded reconsideration request from the plan.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. The plan provided documentation showing this claim was covered at the time of purchase for the plans cost share amount for a 90 day supply of the drug. The amount was reversed because you disagreed with the copay amount. We reviewed the plans Evidence of Coverage and determined the copay for a 90 day supply of a Tier 4 drug, purchased at a standard retail pharmacy is $285, which is the amount charged to you for the Prolia. The amount of the copay was based on the drug's tier, place of purchase and quantity of drug. We have determined that the plan was correct in its calculation of the copay for the Prolia and is not required to allow the lower copay amount requested.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus Solostar solution pen prescribed for unknown diagnosis. The documentation shows Lantus Solostar is a non-formulary drug approved by the plan for dates of service August 14, 2020, through November 12, 2021. You are requesting reimbursement for the Lantus Solostar solution pen filled on October 19, 2020. We received a reconsideration request.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. The record shows you purchased Lantus Solostar solution pen at the full price from a preferred retail pharmacy. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, documentation was provided showing that this claim was covered by the plan at the time of purchase. However, proof of payment in the form of a receipt or physicians billing statement showing the amount that you paid was not provided. Therefore, we determined that the plan is not required to reimburse you without the required documentation. Please submit proof of payment to your plan for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24-26 milligrams tablets, quantity 180 for 90 days prescribed for chronic systolic (congestive) heart failure. This case was auto-forwarded. 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.Entresto 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

At issue is Tegretol XR 200 milligram tablets prescribed twice daily for seizures. The Part D plan denied your request for a tiering exception. 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. The requested drug is being provided by your plan under a formulary exception. Tegretol XR 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.    A physician reviewed your appeal and determined that the plan is not required to cover Tegretol XR because non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 250 milligram capsules prescribed daily following a kidney transplant that was performed on December 29, 2020. The Part D plan denied your request to cover the medication under Part D. 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 other information submitted at the reconsideration level.The record shows that your doctor prescribed Mycophenolate Mofetil as an immunosuppressive drug following your kidney transplant. Medicare records indicate you were covered under Part A at the time of your transplant. Therefore, Mycophenolate Mofetil is covered under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law. As such, our decision is that the Part D plan is not required to cover Mycophenolate Mofetil. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Steglatro 15 milligram tablets to treat the diagnosis of type II diabetes. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan.We performed an independent and de novo review. To make our decision, we read 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. However, Steglatro is not on the plans formulary. 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methadone Hydrochloride 10 milligrams prescribed three times a day for degenerative joint disease. The Part D plan denied coverage because the request did not meet the plans quantity exception requirements. The plan requires prior authorization for quantities exceeding an accumulated morphine equivalent dose of 200 milligrams per day. 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 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 doctor prescribed Methadone Hydrochloride to treat your condition. The Medicare approved compendia does support the use of this drug for your condition. However, there are quantity limitations. 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 Methadone Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 microgram/actuation inhaler to treat chronic obstructive pulmonary disease.   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 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 Cyclobenzaprine Hydrochloride 5 milligram tablets to treat skeletal muscle spasms due to a chronic musculoskeletal condition. We received a reconsideration request. We performed and independent and de novo review. To make our decision we reviewed all documentation submitted. We also researched the plans 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 for long term therapy use. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our Physician Reviewers opinion is that the plan is not required to cover Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

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.Potassium Citrate ER is a generic drug on Tier 3 of the plans formulary. The prescriber submitted a supporting statement. The type of renal stones was not specified in the prescriber statement.  The statement said that Allopurinol is not a medically appropriate alternative to Potassium Citrate ER because the enrollee requires a citrate rather than urate treatment to suppress their kidney stone formation.  Relevant medical records were requested.  However, medical records have not been submitted to support this statement. As such, 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 Repatha Sureclick 140 milligram/milliliter solution auto-injector. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Repatha Sureclick 140 milligram/milliliter solution auto-injector is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception. There are no lower tiered brand drugs of the same type to treat the enrollee's condition.
Appeal type: Prescription Drug
Decision: Favorable

You requested Procrit 40,000 units/milliliter prescribed for myelodysplastic syndrome. The Part D plan denied your request because the prior authorization criteria were not met. Specifically, there was insufficient documentation to support the prior authorization criteria had been met. 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 medical records show the doctor prescribed Procrit to treat your condition. The Medicare approved compendium does support the use of this drug for this condition. The medical records show that the enrollees hemoglobin levels were less than 12 grams/deciliter.We determined that prior authorization can be given and the plan is required to cover the Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 25 milligram tablets to treat the diagnosis of overactive bladder. 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.Myrbetriq is a brand name drug on Tier 3 of the plans formulary. There are no generic or brand name drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Lyrica 100 milligram capsules. 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. The documentation indicates that Lyrica was prescribed to treat the enrollees head pain due to trigeminal neuralgia. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. 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 the Lyrica.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Panzyga prescribed every three weeks for Miller-Fisher syndrome. The Part D plan denied the request because prior authorization criteria was 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 record shows the enrollee will receive Panzyga through an infusion pump in the home infused by a home health nurse. This biologic is eligible for coverage under Medicare Part B. We determined that the plan is not required to cover Panzyga. We cannot consider prior authorization for a biologic the Part D plan cannot cover.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lipitor 10 milligram tablets daily to treat 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 also researched Medicare systems and reviewed the enrollment data available. 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Lipitor 10 milligram tablets. A physician reviewed your appeal and determined that the plan is not required to cover Lipitor 10 milligram tablets because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Otezla 30 milligram tablet prescribed twice daily for rheumatoid arthritis. The Part D plan denied the off-formulary request because the condition is not a medically accepted indication. 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.The records show Otezla was ordered to treat the enrollees rheumatoid arthritis. However, the Medicare approved compendia do not support the use of this drug for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Otezla.