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

You requested Xeljanz (Tofacitinib Citrate) 5 milligram tablet prescribed twice daily for rheumatoid arthritis. Your Part D plan denied the appeal because Xeljanz is a Specialty Tier drug and is not eligible for a cost-share tiering exception. 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 record shows your doctor prescribed Xeljanz to treat your rheumatoid arthritis. Your plans formulary shows that Xeljanz is a Tier 5, Specialty Tier drug. Medicare does not allow a cost-sharing tiering exception for a Specialty Tier drug.A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz because a Specialty Tier drug is not eligible for a cost-share tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess (Linaclotide) 145 micrograms prescribed daily for constipation. You asked the Part D plan to provide a cost-sharing tiering exception. The plan denied the appeal because there are no brand name drugs of the same type in the lower tiers that treat your condition. 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.Your medical records show your doctor prescribed Linzess for your constipation. A Medicare approved compendium supports the use of the requested drug for your condition. However, Linzess is a brand name drug on Tier 4 of your plan's formulary. There are no brand name drugs of the same type in the lower tiers. Therefore, the requested drug is not eligible for a cost-sharing tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Linzess because there are no brand name drugs of the same type in the lower tiers for your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 30 milligram tablet prescribed two tablets twice daily for hyperlipidemia due to hypothyroidism. 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.Armour Thyroid is not on the plan's formulary. The prescriber has not presented medical documentation as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewer's opinion is that the plan is not required to cover Armour Thyroid because the formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride prescribed once daily for chronic low back pain. The Part D plan denied your request because the diagnosis provided does not meet the requirements of a Food and Drug Administration 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 Cyclobenzaprine Hydrochloride to treat your chronic low pain. However, the Medicare approved compendium does 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 Cyclobenzaprine Hydrochloride because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 2.5 milligram tablets prescribed for unknown diagnosis. The plan denied reimbursement because a claim had already been processed for the medication with the same prescription fill date. You are requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.The Part D QIC conducted an independent and de novo review of this request for coverage. The QIC reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased Eliquis from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. 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 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. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We have determined that reimbursement for the copay amount cannot be allowed for the Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Furosemide 40 milligram tablets prescribed for unknown diagnosis. The plan denied reimbursement because a claim had already been processed for the medication with the same prescription fill date. You are requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.The Part D QIC conducted an independent and de novo review of this request for coverage. The QIC reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased Furosemide from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. 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 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. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We have determined that reimbursement for the copay amount cannot be allowed for the Furosemide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 300 milligram capsules prescribed for unknown diagnosis. The plan denied reimbursement because a claim had already been processed for the medication with the same prescription fill date. You are requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.The Part D QIC conducted an independent and de novo review of this request for coverage. The QIC reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased Gabapentin from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. 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 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. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We have determined that reimbursement for the copay amount cannot be allowed for the Gabapentin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydralazine 25 milligram tablets prescribed for unknown diagnosis. The plan denied reimbursement because a claim had already been processed for the medication with the same prescription fill date. You are requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.The Part D QIC conducted an independent and de novo review of this request for coverage. The QIC reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased Hydralazine from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. 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 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. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We have determined that reimbursement for the copay amount cannot be allowed for the Hydralazine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone acetaminophen 7.5-325 milligram tablets prescribed for unknown diagnosis. The plan denied reimbursement because a claim had already been processed for the medication with the same prescription fill date. You are requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.The Part D QIC conducted an independent and de novo review of this request for coverage. The QIC reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased Hydrocodone acetaminophen from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. 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 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. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We have determined that reimbursement for the copay amount cannot be allowed for the Hydrocodone acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lisinopril 40 milligram tablets prescribed for unknown diagnosis. The plan denied reimbursement because a claim had already been processed for the medication with the same prescription fill date. You are requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.The Part D QIC conducted an independent and de novo review of this request for coverage. The QIC reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased Lisinopril from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. 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 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. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We have determined that reimbursement for the copay amount cannot be allowed for the Lisinopril.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol tartrate 50 milligram tablets prescribed for unknown diagnosis. The plan denied reimbursement because a claim had already been processed for the medication with the same prescription fill date. You are requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.The Part D QIC conducted an independent and de novo review of this request for coverage. The QIC reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased Metoprolol tartrate from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. 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 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. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We have determined that reimbursement for the copay amount cannot be allowed for the Metoprolol tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tamsulosin .4 milligram capsules prescribed for unknown diagnosis. The plan denied reimbursement because a claim had already been processed for the medication with the same prescription fill date. You are requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.The Part D QIC conducted an independent and de novo review of this request for coverage. The QIC reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased Tamsulosin from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. 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 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. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We have determined that reimbursement for the copay amount cannot be allowed for the Tamsulosin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for lumbar spondylosis. 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 Lidocaine for lumbar spondylosis. 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: Favorable

You requested Vemlidy (Tenofovir Alafenamide) 25 milligrams prescribed one tablet daily for human immunodeficiency virus. The Part D plan denied your request because Vemlidy is not approved by the Food and Drug Administration or supported by a Medicare approved drug compendia. 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. Your medical records show your doctor prescribed Vemlidy to treat your human immunodeficiency virus. The Medicare approved compendium American Hospital Formulary ServiceDrug Information shows that Vemlidy is used for the treatment of human immunodeficiency virus infection as an antiretroviral agent. A physician reviewed your appeal and determined that the plan is required to cover Vemlidy because your treatment regimen supports the drug is being used in accordance with the Medicare compendia guidelines.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid (Levothyroxine Sodium) 50 microgram tablet prescribed once daily for hypothyroidism. 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.Synthroid is a brand drug on Tier 2 drug on the plan's formulary. The prescriber did not submit medical documentation as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewer's opinion is that the plan is not required to cover the tiering exception for Synthroid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Acid Delayed Release 180 milligram tablet prescribed for lupus nephritis. The Part D plan denied your request because the diagnosis provided does not meet the requirements of a Food and Drug Administration 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 Mycophenolate Acid Delayed Release to treat your Lupus nephritis. However, the Medicare approved compendium does 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 Mycophenolate Acid Delayed Release because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for tiering exception for Bupropion Hydrochloride Extended Release 300 milligram tablet prescribed for mood disturbance. The Part D plan denied your tiering exception request because the diagnosis provided does not meet the requirements of a Food and Drug Administration 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 records show your doctor prescribed Bupropion Hydrochloride Extended Release to treat your mood disturbance. 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 request is denied because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix (Varicella Zoster Vaccine Recombinant) 50 micrograms/0.5 milliliter intramuscular prescribed for shingles prevention. The plan denied the appeal because there are no brand name drugs of the same type in the lower cost-sharing tiers that treat your condition. 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.The records show your doctor prescribed Shingrix for shingles prevention. A Medicare approved compendium supports the use of the requested drug for your condition. However, Shingrix is a brand name drug on Tier 4 of your plan's formulary. There are no brand name drugs of the same type in the lower cost-sharing levels. Therefore, the requested drug is not eligible for a cost-sharing tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Shingrix as a cost-sharing tiering exception because there are no brand name drugs of the same type in the lower tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent (Dupilumab) Injection 300 milligrams/2 milliliters prescribed subcutaneously to treat atopic dermatitis. The Part D plan denied the request because the drug is not on the plans formulary. 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 records show that your doctor is prescribing Dupixent for your atopic dermatitis. Dupixent is not on the plan's formulary. The prescriber has not submitted medical documentation indicating why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported.Our Physician Reviewer's opinion is that the plan is not required to cover Dupixent because the formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xtampza 36 milligram capsule prescribed for severe chronic pain. The Part D plan denied your request because this opioid 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 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 records show your physician prescribed Xtampza 36 milligram capsule to treat your severe chronic pain. This drug has already been approved for a 30 day supply by the Part D plan. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover the requested 90 day supply. It is noted that you were granted a quantity limit exception for Xtampza for the 2020 plan year by an Administrative Law Judge. However, the plan is only required to cover your exception for the plan year granted. Therefore, the Administrative Law Judge decision is not dispositive.A physician reviewed your appeal and determined that the plan is not required to cover a 90 day supply of Xtampza, as the drug exceeds the number of doses that may be dispensed during a specific period of time.