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

At issue is Cyclosporine, Modified 100 milligram/milliliter solution prescribed for chronic urticaria. 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.The documentations submitted show the prescriber ordered Cyclosporine, Modified for chronic urticaria refractory to treatments including antihistamines, oral steroid and Xolair. The Medicare-approved compendia do contain citations to support the use of the requested drug, for treatment of chronic urticaria not adequately respond to at least 2 weeks of treatments with second-generation antihistamines at standard doses. There was peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. A physician reviewed your appeal and determined that the plan is required to cover Cyclosporine, Modified.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Abilify Maintena ER 400 milligram Syr 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.The record shows you filled a prescription for Abilify Maintena ER 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 or provide the pharmacy your Part D plan information to request reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 10 milligram tablets 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.  Farxiga 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 a request for coverage of Retacrit 2000 units prescribed for chronic kidney disease and anemia. 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 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 shows Retacrit was prescribed to treat chronic kidney disease and anemia. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Retacrit. 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 a request for coverage of Alprazolam 1 milligram tablet prescribed for an unknown diagnosis. The Part D plan denied your request because the plans prior authorization requirements were not met.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 asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested.Without a diagnosis it cannot be established that Alprazolam 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, Alprazolam is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage under Part D, the plans prior authorization requirements are not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover Alprazolam.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Benlysta 200 milligram per milliliter subcutaneous auto injection pen to be given weekly for the treatment of active systemic lupus erythematosus. The Part D plan denied the request for coverage because the documentation did not support that the enrollee was auto antibody positive (i.e., anti-nuclear antibody titer greater than or equal to 1:80 or anti-dsDNA level greater than or equal to 30 international units per milliliter).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 medical records submitted at reconsideration include laboratory results obtained on August 6, 2021, which show the enrollees anti-nuclear antibody titer was 1:80. Therefore, the results confirm that the enrollee is auto antibody positive with an anti-nuclear antibody titer greater than or equal to 1:80. The medical records support that the enrollee does not have severe active lupus nephritis or severe active central nervous system lupus. Additionally, the prescriber has noted that the Benlysta will not be used in combination with other biologics or intravenous cyclophosphamide. The medical records show that the enrollee has tried and failed other standard of care treatments for systemic lupus erythematosus, including Methotrexate and Plaquenil, and is currently on Prednisone. The documentation validates that the Benlysta is being prescribed by a rheumatologist. Therefore, the plans prior authorization requirements for coverage of Benlysta have been met. The plan has no quantity limit or step therapy requirements for the drug. A physician reviewed the appeal and determined that the Benlysta is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Diltiazem CD CAP 120MG/24HR prescribed for an unknown diagnosis. The Part D plan denied the enrollee's request for additional reimbursement. 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 enrollee submitted documentation that shows a refill of Diltiazem CD CAP 120MG/24HR was requested from a mail order pharmacy, and shipping was delayed because of a manufacturer shortage. The prescription for the drug was then filled at a local pharmacy and the enrollee was charged a copay of $45. According to the plans 2021 Evidence of Coverage, the copay for a 90 day supply of a Tier 1 drug at a standard in-network pharmacy is $45. Therefore, we determined the plan's copay charge was correct and no further reimbursement is required.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epclusa 400 milligram-100 milligram tablets prescribed for chronic hepatitis C virus infection. 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 records 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 enrollee needs this medication. We did not receive the documentation requested. The documentation submitted indicates the prescriber ordered Epclusa for chronic hepatitis C virus infection, Genotype 1. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Epclusa. 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 Deferasirox 360-milligram tablet to treat chronic iron overload due to blood transfusion. 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.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  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 Astagraf XL 1 milligram capsules prescribed for prophylaxis against cardiac transplant rejection. 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 file carefully. We reviewed all documentation submitted.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 enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. We received the requested information and included it in this 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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Astagraf XL.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent topical patch prescribed as directed for bilateral primary osteoarthritis of the hip. 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 shows your doctor prescribed Lidocaine 5 percent topical patch to treat your bilateral primary osteoarthritis of the hip. 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 Lidocaine 5 percent topical patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Trelegy Ellipta 100 microgram-62.5 microgram-25 microgram aerosol powder prescribed for chronic obstructive pulmonary disease. 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.Trelegy Ellipta 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 Lidocaine 5% ointment prescribed for ankle pain due to a sprain. The Part D plan denied the request. The appellant requested a tiering exception and a quantity limit exception, which the plan further denied.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 shows the prescriber ordered Lidocaine 5% ointment for ankle pain due to a sprain. However, the Medicare approved compendia do not support the use of this drug for your condition. As the drug cannot be approved, a tiering exception request cannot be granted. Of note, the prescriber indicated on appeal that the amount allowed by the plan would be sufficient; therefore, the request for a quantity limit exception is also denied.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 4 milligram disintegrating tablet.prescribed. 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. This drug is not included on your plans formulary. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calquence 100 milligram capsule prescribed for Waldenstrom macroglobulinemia. 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. No medical records are 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 Calquence. 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

You requested Buprenorphine Hydrochloride 2 milligram sublingual tablet prescribed for chronic 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. The documentation shows the Buprenorphine Hydrochloride 2 milligram sublingual tablet was prescribed for chronic pain. 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 Buprenorphine Hydrochloride sublingual tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablet. 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. This drug is included on Tier 5 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.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Indocin 50 milligram rectal suppository.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 Indocin 50 milligram rectal suppository during an inpatient stay in the hospital. According to the plan's Evidence of Coverage, if you pay 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 of covered drugs. The enrollee provided a hospital statement showing the drug that was self-administered and the charged amount. However, proof of payment in the form of a receipt was not provided. Therefore, we determined that the plan is not required to reimburse the enrollee for the Indocin 50 milligram rectal suppository.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Jublia 10% topical solution prescribed for onychomycosis of the toenails. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation on hand does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.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 Nucala Solution Auto-Injector 100 millligram/milliliter prescribed for 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 Nucala Solution Auto-Injector to treat your asthma. 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 Nucala Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Mycophenolate Mofetil 500 milligram tablet prescribed for interstitial lung disease. 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. The documentation shows Mycophenolate Mofetil was prescribed for interstitial lung disease However, the Medicare approved compendia do not support the use of this drug for the enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate Moefetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cevimeline Hydrochloride 30 milligram capsules prescribed for sicca from Sjogrens syndrome. 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 enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. We received the requested information and included it in this 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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Cevimeline Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At initial determination, Budesonide 3 milligram Enteric Coated(EC) capsule was prescribed for unspecified noninfective gastroenteritis and colitis. 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.At reconsideration, Budesonide 3 milligram Enteric Coated(EC) capsule was prescribed for other ulcerative colitis without complications. No medical records were provided to support the change in diagnosis. A medically accepted indication cannot be established by the provided records.A physician reviewed your appeal and determined that the plan is not required to cover Budesonide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Olanzapine 20 milligram tablets prescribed as directed for schizoaffective disorder, bipolar type. 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 shows your doctor prescribed Olanzapine to treat your schizoaffective disorder, bipolar type. 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 Olanzapine.