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

At issue is Otezla 30 milligram tablets prescribed for psoriatic arthritis. 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 tier exception for drugs available on their Specialty Tier. Therefore, a tier exception cannot be considered.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 Nexletol 180 milligram tablets to treat hyperlipidemia with statin intolerance.  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.In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, medical records are required. These records were requested from the prescriber, and we did not receive information that could answer these medical necessity issues.  The requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vimpat 100 milligram oral tablet to treat 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.Vimpat is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary 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 grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dofetilde 250 microgram capsules prescribed for atrial fibrillation. 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 received a statement from your physician that Dofetilde was prescribed to treat atrial fibrillation. Dofetilde is a generic 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: Unfavorable

At issue is coverage for Eszopiclone 3 milligram tablets to treat insomnia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Eszopiclone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 200 milligram tablets to treat circadian rhythm sleep disorder, unspecified. 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 Modafinil 200 milligram tablets to treat circadian rhythm sleep disorder, unspecified. 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 Modafinil 200 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 50 milligram tablets prescribed for overactive bladder. 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. Myrbetriq ER is a brand name drug on Tier 4 of the plans formulary. There are no brand name 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

You requested Ertapenem sodium 1 milligram injection 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 plan submitted documentation that shows you were still in the deductible stage for part of the cost for this drug and entered the initial stage for the remaining amount. You are responsible for the full cost of covered drugs until the deductible amount is satisfied. After the deductible was met, the plan calculated reimbursement 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 network pharmacy charged you. We determined the Ertapenem sodium was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Shingrix vial kit 50 micrograms per 0.5-milliliter intramuscular suspension reconstituted for shingles prophylaxis. 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.Shingrix vaccine injection is a biologic on Tier 3 of the plans formulary. There are no drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
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 record shows you were administered the Shringrix vaccine at an in-network pharmacy and was charged $192.33. The vaccine cost was $171.08 with a dispensing fee of $.75 and administration fee of $20.50. 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 in-network pharmacy. 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 that the amount you paid was correctly calculated and applied to your deductible. Therefore, no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol sulfate 2.5 milligram/3 milliliter solution prescribed for chronic obstructive pulmonary disease. 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 the Albuterol sulfate is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Albuterol sulfate. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 10 milligram capsules prescribed for gastroparesis. 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 Dronabinol to treat your gastroparesis. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humalog 100 milligram/milliliter solution prescribed daily 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 Humalog while in the hospital for an amount that is less than or equal to the required coinsurance and copayment amount. We reviewed the plans formulary and Evidence of Coverage. In this case, the documentation shows you were in the coverage gap stage when you purchased the Humalog. The plan paid its share of the cost for the covered drug and you were responsible for your share of the remaining 25%. We determined that the plan is not required to provide additional reimbursement for the Humalog.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Metformin hydrochloride 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. You are requesting reimbursement for Metformin hydrochloride given to you while in the hospital. We researched Medicare resources and found that the repackaged drug Metformin hydrochloride has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to reimburse you for the Metformin hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tamsulosin hydrochloride.4 milligram capsule 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. You are requesting reimbursement for Tamsulosin hydrochloride given to you while in the hospital. We researched Medicare resources and found that the repackaged drug Tamsulosin hydrochloride has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to reimburse you for the Tamsulosin hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pantoprazole sodium delayed release 40 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. You are requesting reimbursement for Pantoprazole sodium given to you while in the hospital. We researched Medicare resources and found that the repackaged drug Pantoprazole sodium has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to reimburse you for the Pantoprazole sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyzulta 0.024 percent drops prescribed for primary open angle glaucoma. 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. You may wish to submit a request to the plan to consider an off-formulary exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tobradex 0.3%-0.1% ointment. 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 the enrollee purchased Tobradex on January 20, 2021. 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 Tobradex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Welchol 625 milligram tablets prescribed 3 tablets 3 times a day to treat mixed 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. Your prescriber indicated that multiple cholesterol medications had been tried but caused extreme leg pain and leg cramps which made the enrollee unable to walk. However, all formulary alternative drugs were not addressed. 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 Welchol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Motegrity 2 milligram tablets prescribed daily for chronic idiopathic constipation. 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. 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 Motegrity.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pregabalin 50 milligram capsules prescribed for spinal stenosis lumbar region, neuralgia and neuritis. 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 presented to the Plan states your doctor prescribed Pregabalin 50 milligram capsules for spinal stenosis lumbar region, neuralgia and neuritis. 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 Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclophosphamide 50 milligram prescribed 2 capsules daily for ovarian cancer. 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 record shows Cyclophosphamide was ordered for the enrollees ovarian cancer with metastasis. However, this drug is eligible for coverage under Medicare Part B. Oral drugs used for cancer treatment that contain the same active ingredient and are used for the same indications as Part B covered chemotherapy drugs furnished incident to a physicians service are eligible for coverage under Part B.We determined that the plan is not required to cover Cyclophosphamide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Rinvoq ER 15 milligram 24 hour extended release tablets. 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 Rinvoq ER has been prescribed for psoriatic arthritis. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover Rinvoq ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Addyi 100 milligram tablets prescribed daily for hypoactive sexual desire disorder.  The Part D plan auto-forwarded 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 determined that the plan is not required to cover Addyi. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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 Synthroid 88 microgram tablet prescribed daily 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.Synthroid 88 microgram tablet is a brand drug on Tier 4 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 Seroquel XR 200 milligram tablets prescribed for bipolar 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. 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. You may wish to submit a request to the plan to consider an off-formulary exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Accu-check softclix lancets 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. We determined that the plan is not required to cover or reimburse you for the Accu-check softclix lancets because they are not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it may be 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.