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

At issue is Buprenorphine Hydrochloride 2 milligram sublingual tablet prescribed 8 tablets per day for chronic pain and back 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.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 and the quantity were needed. We did not receive the documentation requested.The documentation shows the doctor prescribed Buprenorphine sublingual to treat the enrollees chronic pain and back pain. However, the Medicare approved compendia do not support the use of this drug for this condition. In addition, the medical records do not support why an exception to the plans quantity limit is medically necessary.A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidoderm 5% Patch to treat primary generalized osteoarthritis pain. 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.A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records. A reply from the prescriber was received. The medical records document that Lidoderm 5% patch is being prescribed for the treatment of primary generalized osteoarthritis pain.  However, 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 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 Ubrelvy 100 milligram tablet prescribed one to two per day for unspecified headache. 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 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. A prescriber statement was submitted. However, we did not receive the medical records requested.The prescriber statement includes a diagnosis of intractable migraines. However, no medical records were provided by the prescriber to support this diagnosis.  The provided medical records dated 5/19/2021 list the diagnosis in the assessment section as 'headache, unspecified.'   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.A physician reviewed the appeal and determined that the plan is not required to cover Ubrelvy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cincalcet HCL tablet 30 milligram. 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. Cincalcet is a generic drug on Tier 4 of the plans formulary. 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 grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha SureClick Autoinjector140 milligrams per milliliter prescribed every two weeks for familial hypercholesterolemia. 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 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 the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. 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. 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 Flector Patch 1.3% prescribed for primary osteoarthritis. 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 Flector Patch to treat your primary osteoarthritis. 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 Flector Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Aspirin 81 milligram enteric-coated tablets prescribed for a history of cerebrovascular accident, coronary artery disease, and recurrent myocardial infarctions. 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 records submitted at the reconsideration level. Aspirin does not meet the definition of a Part D drug, as this drug is available over the counter without a prescription. Nonprescription drugs are excluded from the Part D benefit. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets prescribed to treat small intestinal bacterial overgrowth.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 Xifaxan 550 milligram tablets to treat small intestinal bacterial overgrowth. 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 Xifaxan 550 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Onetouch Ultra Blue test strip prescribed for the diagnosis of diabetes, type 2. 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 determined that the plan is not required to cover the Onetouch Ultra Blue test strip because it is not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it is covered under Part B. Please submit your request to Medicare Part B. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tremfya 100 milligrams per milliliter syringe prescribed for psoriasis vulgaris. 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 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 the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. 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. A physician reviewed your appeal and determined that the plan is not required to cover Tremfya.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Xifaxan 550 milligram tablets prescribed for irritable bowel syndrome with diarrhea. The Part D plan denied coverage.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 enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee was prescribed Xifaxan to treat irritable bowel syndrome with diarrhea and that the enrollee has not already received an initial 14-day treatment and two additional 14-day treatments with Xifaxan.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cimzia Prefill Kit 200 milligrams per milliliter prescribed 2 milliliters every 28 days for rheumatoid arthritis. The Part D plan denied the 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.This drug is included on Tier 4 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.A physician reviewed your 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 Febuxostat 40 milligram tablets prescribed to treat gout. 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.The documentation shows Febuxostat 40 milligram tablets was prescribed to treat gout. The prescribers statement and a clinic note fail to support the diagnosis of gout for the requested drug. No medical records have been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.A physician reviewed your appeal and determined that the plan is not required to cover Febuxostat 40 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

Trulicity 0.75-milligrams/0.5-milliliters Pen (8 pens) per 28-days was requested to treat the enrollees diabetes mellitus. The Part D plan denied your request because the amount requested was greater than the plan's dispensing limit.  As well, the plan received a tiering exception 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.A request was submitted to the prescriber to address the quantity limit criteria and to provide supporting medical records. A reply from the prescriber was not received. The plan limits the amount of Trulicity Pen 0.75-milligrams/0.5-milliliters to 2-milliliters (4 pens) per 28-days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. Additionally, Trulicity is a biologic drug on Tier 3 of the plans formulary. There are no lower tiered biologic drugs of the same type to treat the same 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 the requested drug at the quantity ordered and that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

You requested Sensipar 30 milligram tablet prescribed daily for hyperparathyroidism and chronic kidney 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 information submitted at the reconsideration level. At reconsideration, physician office notes are provided dated April and May, 2021, that clearly document this enrollee has primary hyperparathyroidism, hypercalcemia, and who is not a surgical candidate. This is a medically accepted indication per MicroMedex; Cinacalcet is approved to treat primary hyperparathyroidism in patients with serum calcium levels indicating parathyroidectomy, but who are unable to undergo surgery. The Medicare approved compendia support the use of this drug for your condition.A physician reviewed your appeal and determined that the plan is required to cover Sensipar.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Procrit Solution 4000 units/milliliter prescribed weekly for anemia in neoplastic 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 information submitted at the reconsideration level. The documentation shows your doctor prescribed Procrit Solution to treat your anemia in neoplastic disease. 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 Procrit Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Fasenra 30 milligram per milliliter prescribed daily for mild intermittent asthma. 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 Fasenra to treat your mild intermittent asthma with frequent exacerbations. 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 Fasenra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Frovatriptan Succinate 2.5 milligram tablet to treat chronic migraine, without aura, without status migrainosus, not intractable and occipital neuralgia. 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 record shows you are prescribed Frovatriptan Succinate to treat your chronic migraine headaches. We asked the prescriber to send us a prescriber statement, prior authorization, treatments tried and failed, and medical records. We received the documentation and included it in our review.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 Opsumit 10 milligram oral tablet prescribed daily for pulmonary arterial 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 Opsumit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Admelog Solostar 100 units per milliliter pen. 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 record shows you filled a prescription for Admelog Solostar at a network 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 drug 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

You requested Hysingla ER 60 milligram tablet one per 30 days prescribed for lung cancer. 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. Medicare rules state that for prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must be for treatment of a condition that is completely unrelated to the terminal condition(s) or related conditions for which hospice coverage is being provided. The record shows Hysingla is being used for treatment of a condition that is related to hospice. However, your drug appears to be eligible for Part A coverage. We determined that the Part D plan is not required to cover the Hysingla. Please submit your request to Medicare Part A. 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

You requested Brompheniramine-PseudoephedDM syrup prescribed for unknown diagnosis. 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.According to Medicare rules, drugs used for the symptomatic relief of cough and cold are excluded from coverage. Therefore, we determined that the plan is not required to cover the Brompheniramine-Pseudoephed-DM syrup.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azithromycin 500 milligram tablet prescribed for unknown diagnosis. 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 record shows you purchased Azithromycin 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Latanoprost 0.005% eye drops. 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 this medication. We did not receive the documentation requested.The documentation includes valid proof of payment. However, there were no medical records submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to reimburse Latanoprost.