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

At issue is Atorvastatin 20 milligram tablets. The enrollee is requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request from the plan to reconsider the appeal.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 the enrollee purchased Atorvastatin on December 11, 2020. The amount of the copayment was based on the drug's tier and place of purchase. 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. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We have determined that reimbursement for the copay amount cannot be allowed for the Atorvastatin.
Appeal type: Prescription Drug
Decision: Favorable

You requested reimbursement for a Diphtheria and Tetanus Toxoids, and Acellular Pertussis vaccine (Adacel). The Part D plan denied your request because you did not submit a valid National Drug Code number for the medication you received, which is required to process your request for reimbursement. 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. You have submitted the correct National Drug Code number for the vaccine, which is 49281-400-20, at reconsideration. Furthermore, the other required documentation has been submitted, including your membership information (name, date of birth, and member number); the prescriber's name and address; the pharmacy name and address; the amount of medication you received; and the cost you paid for the medication.Therefore, we have determined that the Part D plan is required to reimburse you for the cost of the Diphtheria and Tetanus Toxoids, and Acellular Pertussis vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lantus 100 units/milliliter prescribed daily for an unknown diagnosis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. The documentation shows you received the Lantus from your pharmacy on December 23, 2020. However, we have no medical records to determine if the drug you received was medically necessary. A physician reviewed your appeal and determined that the plan is not required to reimburse you for the Lantus.
Appeal type: Prescription Drug
Decision: Favorable

You requested Nuplazid 34 milligrams prescribed daily for psychosis related to Parkinsons disease. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Nuplazid to treat your psychosis related to Parkinsons disease. The Medicare approved compendia supports the use of this drug for your condition.A physician reviewed your appeal and determined that the plan is required to cover the Nuplazid.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mirconized Progesterone 100 milligram capsules to treat endometrial hyperplasia prophylaxis in an enrollee on post-menopausal estrogen therapy.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  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 enrollees date of birth is consistent with a post-menopausal age.  There are recent paid claims for estrogen and a prescribers statement. A Medicare approved compendium, DrugDex, indicates Oral micronized progesterone is indicated for use in the prevention of endometrial hyperplasia in non-hysterectomized postmenopausal women who are receiving conjugated estrogen tablets.  This supports a medically accepted indication.  Additionally, no formulary alternatives for the enrollees condition, as prescribed, are identified.  Therefore, the requested drug is eligible for coverage under Medicare Part D with a formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Omega-3-acid ethyl esters 1 gram capsules prescribed as directed for coronary artery disease and hypertriglyceridemia. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records show you were prescribed Omega-3-acid ethyl esters for hypertriglyceridemia. The documentation shows the enrollees triglyceride level was 109 milligrams per deciliter on September 9, 2020. The Medicare approved compendia do not support the use of this drug for the enrollees condition unless the triglyceride level is 500 milligrams per deciliter or higher. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Omega-3-acid ethyl esters at issue.
Appeal type: Prescription Drug
Decision: Favorable

You requested Revlimid 20 milligram capsules for the treatment of - previously untreated Follicular Lymphoma, low grade, stage IV, high tumor burden, FLIPI 3  International Classification of Diseases-10 code (C82.02). The Part D plan denied the request, as patient will be enrolled in a clinical trial, indicated by the plan as having a sponsor not on a list of qualifying federal agencies. 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 regulations and Medicare approved compendia.The following citation in the National Comprehensive Cancer Network, a Medicare approved compendium, supports the use of the requested drug for your condition: B-Cell Lymphomas - Follicular Lymphoma (grade 1-2) - Used in combination with rituximab (preferred) or obinutuzumab as first-line therapy for stage I, contiguous stage II, non-contiguous stage II disease, or for patients with indications for treatment with stage III or IV disease.'  Therefore, it is considered a medically accepted indication. The addition of a third drug, acalabrutib, is part of a clinical trial, NCT04404088, sponsored by MD Anderson Medical Center, and funded by the National Institutes of Health. (Per clinicaltrials.gov)The documentation indicates the drug is being used for a medically accepted indication, and also satisfies the plans coverage criteria  a diagnosis of Follicular Lymphoma as first line therapy. 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 Shingrix vaccine. The Part D plan denied the request because the plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. 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.The record indicates the enrollee received the Shingrix vaccine at the primary care physicians office. However, no medical records were received. The out-of-network criteria was not met. We determined that the plan is not required to reimburse you for the Shingrix vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Topiramate 100 milligram tablet prescribed twice daily for bipolar I disorder. The Part D plan denied your request because the drug is not a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Topiramate to treat your condition. 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 the Topiramate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Corlanor 7.5 milligram tablet twice a day prescribed for orthostatic hypotension. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Corlanor for orthostatic hypotension. The Reconsideration appeal letter darted February 23, 2021 states that the requested drug is being used to control the enrollee's heart rate and that the enrollee's diagnoses are orthostatic hypotension and paroxysmal atrial fibrillation.  The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clonazepam 1 milligram prescribed daily for the enrollees condition. The Part D plan denied your request because the drug is limited to a recurring 30 day supply. 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.We asked you to send us a supporting statement to show why the Clonazepam is medically necessary. However, we did not receive the documentation.A physician reviewed your appeal and determined that the plan is not required to cover the Clonazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Premarin vaginal cream prescribed as directed to treat asymptomatic menopausal state. 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 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.Your medical records show your doctor prescribed Premarin vaginal cream to treat your condition. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Premarin vaginal cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vascepa 1 gram prescribed as directed for hyperlipidemia. The Part D plan denied coverage because the plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level. Your medical records show you were prescribed Vascepa for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has been met. 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 the Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vemlidy 25 milligrams prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for a lower cost-sharing tier. We received an standard 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.Vimlidy is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier are 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 Cyclobenzaprine hydrochloride 10 milligram tablets prescribed as directed. At initial determination and redetermination, the diagnoses of skeletal muscle spasm and degenerative disc disease were given. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. The Part D plan also denied your request because the prior authorization criteria were 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. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records to show the need for this medication. We received additional documentation and it is included in this review. The prescriber statement indicates the enrollee had a cervical fusion in the past and still suffers from daily muscle spasms in the neck. The prescriber did not specify if this is an acute or chronic condition but did note the enrollee has taken this medication since 2013. 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.A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine hydrochloride.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Aimovig 70 milligram\milliliter auto-injector pen prescribed as directed for migraines, for continuation of therapy. The Part D plan denied coverage because the prior authorization criteria were 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 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. A letter from the prescriber on February 17, 2021, indicates that migraine frequency has decreased 66% while using Aimovig. This would satisfy the plan's prior authorization criteria for continuation of therapy till the end of the plan year.A physician reviewed your appeal and determined that the plan is required to cover the Aimovig.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Xeljanz 5 milligram tablets prescribed for alopecia areata, unspecified. The Part D plan denied your prior authorization request because the medication was not prescribed for a medically accepted indication. 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 information submitted at the reconsideration level. The record shows you were prescribed Xeljanz for alopecia areata, unspecified. In review of the Medicare approved compendia, alopecia areata, unspecified is not a medically accepted indication for Xeljanz. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Xeljanz at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Rytary ER (Carbidopa 23.75 milligrams/Levodopa 95 milligram) capsules prescribed daily for Parkinsons disease. The Part D plan denied your request for a tiering exception because Rytary XR is a brand name Tier 4 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 record shows Rytary ER is being prescribed for Parkinsons disease. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Rytary ER is a brand name Tier 4 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

You requested coverage for Corlanor 7.5 milligram tablets prescribed for inappropriate sinus tachycardia. The Part D plan denied your prior authorization request because the medication was not prescribed for a medically accepted indication. 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 information submitted at the reconsideration level. The record shows you were prescribed Corlanor for inappropriate sinus tachycardia. In review of the Medicare approved compendia, inappropriate sinus tachycardia is not a medically accepted indication for Corlanor. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Corlanor at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium gel 1%. The Part D plan denied coverage because there was insufficient documentation to support that the prior authorization criteria were met. We received an expedited 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 records submitted at the reconsideration level. The physician submitted a supporting statement. The prescriber statement indicates the physician had prescribed Diclofenac Sodium for pain in the knees, hands, and elbows.However, the plan requires documentation of an intolerance or a contraindication to two oral nonsteroidal anti-inflammatory drugs before treatment with the requested drug. The documentation available for review 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 Diclofenac Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol 10 microgram vaginal tablet prescribed for lichen sclerosus. The Part D plan denied your request for a tiering 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 asked your prescriber to send us information about 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 similar medications on the lower tiers would not work for you. However, we did not receive the documentation.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 Nurtec 75 milligram tablets to treat vestibular migraine and intractable migraine. 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 Nurtec. A physician reviewed your appeal and determined that the plan is not required to cover Nurtec because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ingrezza 20 milligram capsules prescribed for tardive dyskinesia. 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 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. The documentation supports Ingrezza was prescribed for tardive dyskinesia. However, the enrollee does not satisfy the plan's coverage criteria. The documentation does not support that the enrollee scored at least a 3 on item 8 of the Abnormal Involuntary Movement Scale.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.