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

At issue is Hydroxychloroquine 200 milligram tablet. The Part D plan denied the 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 requested additional information from the prescriber to confirm a diagnosis but did not get a response. In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, documentation supporting a medically accepted indication are required. The information was insufficient to determine medical necessity and if the drug is eligible for coverage under Part D benefits. A physician reviewed your appeal and determined that the plan is not required to cover Hydroxychloroquine.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Topiramate 25 milligram tablets, one tablet daily. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. The only prior authorization requirement listed in the Part D plans formulary for Topiramate is that coverage will not be provided if the drug is prescribed for weight loss or smoking cessation. The submitted medical records indicate that Topiramate has been prescribed for migraine prophylaxis. Migraine prophylaxis is a medically accepted indication for the use of Topiramate, as outlined in the Medicare approved compendia. Therefore, the submitted documentation supports that the plans coverage requirements have been met and that the drug is being prescribed for a medically accepted indication. There are no quantity limit or step therapy requirements for the drug. As such, coverage for the drug can be allowed. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis 0.05 percent emulsion prescribed as directed. The Part D plan denied your request for a tiering 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. Restasis 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

At issue is NP Thyroid 90 milligram tablets prescribed as directed for hypothyroidism in an enrollee with a history of Grave's disease and prior treatment with radioactive iodine. 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. Non-FDA approved drugs are excluded from Medicare Part D coverage.  Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to cover NP Thyroid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colesevelam Hydrochloride 625 milligram tablet prescribed as directed for hypercholesterolemia. 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 grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. 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. A physician reviewed your appeal and determined that the plan is not required to cover Colesevelam Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Viagra 100 milligram tablet. The Part D plan denied the 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 requested additional information from the prescriber to confirm a diagnosis but did not get a response. In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication and is not an excluded drug use, as required by Medicare, documentation supporting a medically accepted indication is required. The information was insufficient to determine medical necessity and if the drug is eligible for coverage under Part D benefits. A physician reviewed your appeal and determined that the plan is not required to cover Viagra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Halobetasol Propianate 0.05% topical cream prescribed for the treatment of psoriasis. The Part D plan denied the 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. Halobetasol Propianate topical cream is a generic drug on Tier 4 of the plans formulary. The prescriber has not addressed all generic drugs of the same type on the lower tier of the plans formulary to treat the enrollees condition as to whether the drugs have been tried and failed, or are contraindicated. Therefore, the tiering exception criteria have not been met. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier. The drug will continue to be covered at the Tier 4 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate Nebulizer Solution 2.5 milligram/3 milliliter. The Part D plan denied the request as not on the plans formulary.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. Albuterol Sulfate Nebulizer 2.5 milligram/3 milliliter is on Tier 2 of the plans formulary. However, this drug is used via a nebulizer and there is no indication the enrollee is in a skilled nursing facility or an inpatient in the hospital covered under Part A. This drug is not eligible for coverage under Part D drug benefits. However, this drug may be covered under Medicare Part B benefits. We determined that the plan is not required to cover Albuterol Sulfate Nebulizer Solution 2.5 milligram/3 milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 20 milligram tablets prescribed to treat an enrollees condition. The Part D plan denied the appeal request for a tiering exception.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.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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rituxan 100-milligrams/10-milliliters Intravenous Solution. At initial determination and redetermination the diagnosis of chronic nephritic syndrome with diffuse membranous glomerulonephritis was given. 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.At reconsideration a diagnosis of nephrotic syndrome with glomerular abnormality was given. However, 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Guanfacine Hydrochloride 1 milligram tablet prescribed as directed for essential (primary) hypertension. 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 grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Guanfacine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Inveltys 1% ophthalmic suspension. 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 Inveltys 1% ophthalmic suspension has been prescribed for the treatment of dry eye syndrome due to history of cataract surgery in 2007. 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 drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cresemba 186 milligram capsules prescribed as directed for cerebral cryptococcosis. 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 documentation shows your doctor prescribed Cresemba to treat your cerebral cryptococcosis. 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 Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Rosuvastatin 5 milligram tablet for unknown diagnosis. The Part D plan denied the enrollees 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 the enrollee received a 30 day supply of Rosuvastatin on June 21, 2021 prior to the plans approval, and paid the full cost of the drug. A 90 day supply was received by the enrollee on July 7, 2021 and was processed through the plan as the initial fill for the Rosuvastatin and cost share was applied. The plan provided a claim transaction detail that indicates the next eligible fill date is September 26, 2021. According to the plans Evidence of Coverage, limits and restrictions are placed on drugs that are refilled too soon. Therefore, the claim for fill date June 21, 2021 does not qualify for reimbursement as it was purchased prior to the plan's approval. 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 Pregabalin 50 milligram capsule prescribed for neuralgia and neuritis, unspecified. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. The medical records indicate that the enrollee is prescribed Pregabalin for neuralgia and neuritis, unspecified. 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 Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium Bromide-Albuterol Sulfate 0.5-2.5 (3) milligrams per 3 milliliters nebulizer solution prescribed to treat an enrollee with chronic obstructive pulmonary disease. The Part D Plan denied the appeal request.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 record shows Ipratropium Bromide-Albuterol Sulfate is being administered through a nebulizer in the home setting. 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 Part D plan is not required to cover the Ipratropium Bromide-Albuterol Sulfate. 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 Tirosint 100 microgram capsules. The Part D plan denied the appeal request for a tiering exception.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.Tirosint 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

The enrollee requested Shingrix 50/0.5 milliliter injection prescribed for shingles vaccination. 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 record shows the enrollee received the Shingrix vaccine at the enrollees physicians office. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or provider's office. 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. The plans formulary shows the drug is covered as a Tier 1 drug. The documentation submitted includes a statement from the physicians office that shows the Shingrix vaccine and administration fee was paid in full by the enrollee. Therefore, we determined that the plan is required to reimburse you for their share of the cost for the Shingrix vaccine and administration fee for date of service June 11, 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Timolol-Brimonidine-Dorzolamide-Latanoprost preservative free 0.5-0.15-2-0.005% solution to treat an enrollee with glaucoma. The Part D plan denied the appeal request.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 record shows the physician prescribed Timolol-Brimonidine-Dorzolamide-Latanoprost preservative free 0.5-0.15-2-0.005% solution. However, the requested drug has not been approved by the United States Food and Drug Administration. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage. 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 Adderall Extended Release 30-milligram tablet to treat attention deficit hyperactivity disorder. 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.We asked your prescriber to send us a prescriber statement, answers to prior authorization coverage criteria, and medical records. However, we did not receive the documentation.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 5 milligram tablets prescribed as directed for rheumatoid arthritis. 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 documentation shows your doctor prescribed Cyclobenzaprine Hydrochloride to treat your rheumatoid arthritis. 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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bosentan 62.5 milligram tablet prescribed for pulmonary arterial hypertension secondary to lupus erythematosus and interstitial lung disease. 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 records submitted at the reconsideration level. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The enrollee has not satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Bosentan. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Austedo 12 milligram tablets prescribed as directed for drug induced subacute dyskinesia. 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 asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. We received the documentation and included it in our review.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Austedo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz 5 milligram tablets prescribed as directed for alopecia areata. 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 documentation shows your doctor prescribed Xeljanz to treat your alopecia areata. 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 Xeljanz.
Appeal type: At-Risk Determination
Decision: Unfavorable

At issue is Hydromorphone Hydrochloride 8-milligram Extended Release tablet to treat chronic pain syndrome and lumbar, post laminectomy syndrome. 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.We asked your prescriber to send us a prescriber statement, to clarify the medical history, to address the nonformulary exception criteria, and to provide supporting medical records.  However, we did not receive the documentation.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. 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. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.