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

You requested Ozempic 0.25 milligram or 0.5 milligram dose (2 milligram/1.5 milliliter) pen injector prescribed as directed for prediabetes and class 3 severe obesity due to excess calories without serious comorbidity with a body mass index (BMI) of 40.0 to 44.9 in adult. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Ozempic to treat your prediabetes and class 3 severe obesity due to excess calories without serious comorbidity with a body mass index (BMI) of 40.0 to 44.9 in adult. However, the Medicare approved compendia do not support the use of this drug for your conditions. 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 Ozempic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dilantin 100 milligram capsules prescribed as directed for a seizure disorder. 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. We also researched Medicare systems and reviewed the enrollment data available.Dilantin is a brand drug on Tier 4 of the plans formulary. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you. 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: Favorable

You requested Gammagard 30 gram/300 milliliter solution prescribed as directed for myelin oligodendrocyte glycoprotein antibody disorder. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Gammagard to treat your myelin oligodendrocyte glycoprotein antibody disorder (MOGAD). MOGAD is a chronic inflammatory demylinating disorder and is therefore included in the orphan drug use, treatment of chronic inflammatory demyelinating polyneuropathy. The Medicare approved compendia support the use of this drug for your condition. Therefore, the drug can be considered for payment under the Part D benefit.   A physician reviewed your appeal and determined that the plan is required to cover the Gammagard.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tolvaptan 15 milligram tablets prescribed for your condition. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. We asked your doctor 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. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. For informational purposes only, enrollee sent a letter indicating he was hospitalized in August and September of 2020 with a diagnosis of hyponatremia (low sodium), and was on Tolvaptan continuously since then. Request is for reimbursement for prescription dispensed on February 8, 2021. No recent hospitalizations are mentioned. Per the Medicare compendia, Micromedex, Tolvaptan should not be used for more than 30 days in order to reduce the risk of hepatic injury.A physician reviewed your appeal and determined that the plan is not required to cover Tolvaptan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Ondansetron 4 milligram tablets prescribed daily for unspecified nausea and vomiting. The Part D plan denied your 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 Ondansetron for unspecified nausea and vomiting. In review of the Medicare approved compendia, unspecified nausea and vomiting is not a medically accepted indication for Ondansetron. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Ondansetron at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Avonex 30 microgram/0.5 milliliter prefilled syringe kit prescribed as directed for relapsing remitting multiple sclerosis. The Part D plan denied your request because the documentation did not support an off-formulary exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. 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 Avonex.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Frovatriptan Succinate 2.5 milligram tablets prescribed for migraines. The Part D plan forwarded the request to us for review. 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. During this review, a prescriber statement and supporting medical records were requested from your doctor. The doctor did not respond to our request.Frovatriptan Succinate is a generic drug on Tier 4 of the plans formulary. The prescribing physician has not addressed why the generic drugs of the same type on the lower tiers of the plans formulary to treat your condition have been tried and failed, or are contraindicated. A physician reviewed the appeal and determined that the plan is not required to grant a lower cost tiering exception to Frovatriptan Succinate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Fiorinal with Codeine #3 30-50-325 milligram capsules. 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 Fiorinal with Codeine #3 has been prescribed for the treatment of migraine headaches.  However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, 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 your appeal and determined that the plan is not required to cover the Fiorinal with Codeine #3.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Corlanor 5 milligram tablets prescribed daily for postural orthostatic tachycardia syndrome. The Part D plan denied your 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 postural orthostatic tachycardia syndrome. In review of the Medicare approved compendia, postural orthostatic tachycardia syndrome 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

You requested a tiering exception for Vascepa 2 gram capsules prescribed for hyperlipidemia. 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. Vascepa is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Vascepa at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vascepa 1 gram capsule to treat pure hypercholesterolemia. 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 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 your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

The record shows the GoodRx discount was applied to the purchase because your insurance information was not up-to-date or not available. According to the GoodRx website (https://www.goodrx.com), you cant combine GoodRx with your insurance to lower your copay. The pharmacy can tell you if we beat the copays for each of your prescriptions. If we do, just ask them to use your GoodRx coupons instead of your insurance (remember the amount you pay with a coupon wont be applied toward your deductible). When you decided to use the GoodRx discount, you acknowledged and agreed that GoodRx will be treated as the primary payor with respect to the medications that you have selected to purchase through the GoodRx discount program. Therefore, the Plan is not required to cover or provide reimbursement for Gabapentin 800 milligram tablets.. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance without applying the GoodRx discount.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tretinoin 0.05% cream. We received an auto-forwarded reconsideration request from the coverage level. 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.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 records show Tretinoin cream was prescribed to treat aging face/brown macules. Agents when used for cosmetic purposes or hair growth are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to cover Tretinoin.
Appeal type: At-Risk Determination
Decision: Unfavorable

You requested a tiering exception for Restasis 0.05 percent eye emulsion prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because Restasis is a brand name Tier 3 drug and there are no generic drugs of the same type on the lower cost sharing levels. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Restasis is a brand name Tier 3 drug. There are no generic 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 Methylphenidate ER 54 milligram tablets prescribed to treat your condition. 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 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.Methylphenidate ER 54 milligram tablet is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why alternative drugs to treat you condition on lower cost-sharing tiers would not work for you. All generic drugs on lower tiers have not been tried. 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: Favorable

At issue is Sofosbuvir Velpatasvir 400-100 milligram tablet prescribed to treat hepatitis C virus. 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. We also researched Medicare systems and reviewed the enrollment data available.The medical records show Sofosbuvir Velpatasvir was prescribed to treat hepatitis C virus. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided indicates the enrollee has failed a prior trial ofSofosbuvir Velpatasvir, has chronic hepatitis C viral infection, decompensated liver disease, and is being treated by a hepatologist who recommends this treatment. In addition, the enrollee is ineligible for Ribavirin due to a history of sickle cell anemia. A 24 week course of treatment is a medically accepted indication for this enrollee's condition. A physician reviewed your appeal and determined that the plan is required to Sofosbuvir Velpatasvir. The physician reviewer also determined the plans prior authorization requirements are met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Ilaris 150 milligram/milliliter vial prescribed daily for hidradenitis suppurativa. The Part D plan denied your 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 Ilaris for hidradenitis suppurativa. In review of the Medicare approved compendia, hidradenitis suppurativa is not a medically accepted indication for Ilaris. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Ilaris at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingles vaccine prescribed for vaccination. The Part D plan denied your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows you requested the plan to reimburse you for a shingles vaccine. However, you did not indicate the name or National Drug Code for the drug, the provider and/or pharmacy, and the date that you were administered the vaccine. Therefore, the plan did not approve coverage. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, 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 vaccine was not provided. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

At coverage determination and redetermination, you requested Dronabinol 2.5 milligram capsules prescribed twice daily for anorexia, and localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus. The Part D plan denied your 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, the diagnosis for use of this drug was anorexia. Drugs prescribed to treat anorexia and/or weight loss, unrelated to AIDS wasting or cachexia due to certain chronic diseases, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix 50 microgram/.5 milliliter suspension prescribed for vaccination. 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 plan submitted documentation that shows you were still in the deductible stage of the Part D benefit when you were administered the vaccination at your physician's office. Your plans Evidence of Coverage states that you are responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined the amount you paid was applied to your deductible and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica 300 milligram capsules prescribed for fibromyalgia. The Part D plan denied your 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 physician submitted a supporting statement. 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. A physician reviewed your appeal and determined that the plan is not required to cover Lyrica.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Inqovi 35 milligram-100 milligram tablet to treat acute myeloid leukemia.  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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colchicine 0.6 milligram capsules prescribed four times daily for Familial Mediterranean fever. 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. We also researched Medicare systems and reviewed the enrollment data available. This drug is provided by the plan under a quantity limit exception. Per Medicare rules, drugs that are granted a quantity limit exception are not eligible for a tiering exception. Therefore, a tier exception cannot be consideredA physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.