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

At issue is Spiriva Respimat 1.25-2.5 micrograms per actuation aerosol solution prescribed for cough, unspecified pneumonia, respiratory disorder, and bronchiectasis. 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.The doctor prescribed Spiriva Respimat to treat the enrollees cough, unspecified pneumonia, respiratory disorder, and bronchiectasis. However, the Medicare approved compendia do not support the use of this drug for these conditions.A physician reviewed the appeal and determined that the plan is not required to cover Spiriva Respimat.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nortriptyline 10 milligram capsule prescribed for zoster with other complications. 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 the Enrollees condition. We also asked for medical records or other documentation to show why the medication is needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.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. A physician reviewed your appeal and determined that the plan is not required to cover Nortriptyline.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lubiprostone 24 microgram capsule prescribed for chronic constipation. 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 medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.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. A physician reviewed the appeal and determined that the plan is not required to cover Lubiprostone 24 microgram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acyclovir 5% cream prescribed for herpetic stomatitis. 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 the Enrollee's condition. We also asked for medical records or other documentation to show why the medication is needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. We did not receive the documentation requested.The documentation shows Acyclovir 5% cream was prescribed for herpetic stomatitis. 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 Acyclovir.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Qvar Redihaler 80 micrograms/actuation prescribed 2 puffs twice a day for mild persistent asthma. 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 medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.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. A physician reviewed the appeal and determined that the plan is not required to cover Qvar Redihaler 80 micrograms/actuation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Qvar Redihaler Aerosol 80 microgram prescribed one to two puffs twice daily as needed for mild intermittent 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 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. However, we did not receive the documentation.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 the appeal and determined that the plan is not required to cover Qvar Redihaler.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Travoprost 0.004% eye drop. 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 asked your prescriber to send us information about the Enrollees condition. We also asked for medical records or other documentation to show why the medication is needed. Specifically, we asked for records to show why similar medications on the lower tiers would not work. However, we did not receive the documentation. Travoprost is a generic drug on Tier 3 of the plans formulary. The prescriber did not address why the drugs available on the lower tiers of your plans formulary would not work. Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 2.5 milligram oral tablet prescribed twice daily for atrial fibrillation. 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. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.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 Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 4 milligram tablets as direcetd. 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 provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. 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 Qvar Redihaler 80 microgram inhaler prescribed daily for mild intermittent 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. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.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, no medical records were submitted to 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 Qvar Redihaler.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Paroxetine Hydrochloride 20 milligram tablets prescribed daily for major depressive disorder. 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 request states the doctor prescribed Paroxetine Hydrochloride to treat the Enrollees major depressive disorder. 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 Paroxetine Hydrochloride. Enrollees over the age of 65 are considered high risk and require prior authorization criteria to be met. 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 Eliquis 2.5 milligram tablet prescribed twice daily. 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 asked the prescriber to send us information about the Enrollee's condition. We also asked for medical records or other documentation to show why the medication is needed. Specifically, we asked for records to show why similar medications on the lower teirs would not work for you.  However, we did not receive the documentation.. Eliquis is a brand drug on Tier 4 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat the Enrollees condition have been tried or deemed contraindicated. 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 Acuicyn Solution 40 milliliters prescribed for 30 days to treat keratoconjunctivitis sicca.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 the prescriber to send us information regarding the Enrollee's condition. We also asked for medical records or other documentation to show why the medication is needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.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 and prescribers statement 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 Acuicyn.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bystolic 10 milligram tablet prescribed daily for essential primary hypertension. 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. We asked your 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. However, we did not receive the documentation.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 the appeal and determined that the plan is not required to cover Bystolic.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Relistor 150 milligram oral tablet prescribed for drug induced 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 asked your prescriber to send us information regarding 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 other medications on the plan's formulary would not work for you. We received the documentation and included it in our review.At initial determination the diagnosis of drug induced constipation was given. However, the Medicare approved compendia do not support the use of this drug for the provided condition. In addition, the medical records submitted for review do not include the enrollees diagnosis. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication. The formulary exception was not addressed because 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 Relistor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% gel prescribed for hypogonadotropic hypogonadism. 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 the prescriber to send us information regarding the Enrollees condition. We also asked for medical records or other documentation to show why the medication is needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation. 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. A physician reviewed your appeal and determined that the plan is not required to cover Testosterone 1.62% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide-Formoterol-Fumarate 160/4.5/microgram aerosol prescribed at unknown frequency for bronchitis. 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. We asked the prescriber to send us information regarding your 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. However, we did not receive the documentation.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 Budesonide-Formoterol-Fumarate aerosol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nifedipine ER 30 milligram tablet prescribed twice daily for hypertension. 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. We asked the prescriber to send us information about the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why similar medications on the lower tiers would not work. We received a prescribers statement. However, we did not receive medical records.Nifedipine ER 30 milligram tablet is a generic drug on Tier 2 of the plans formulary. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work. 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 the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Fentanyl 25 microgram per hour patch prescribed for glioma in the brain. The Part D plan denied your request for additional reimbursement.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 plan submitted documentation that shows the enrollee paid full price for the Fentanyl at an in-network pharmacy. 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. In this case, documentation was provided showing the Medicare contracted price for the prescription was less than the copay for the tier 4 drug. The plan will only reimburse up to the contracted price of the drug and since the price was less than the enrollees copay, no additional reimbursement is due. We determined the plan calculated reimbursement correctly and is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a non-formulary exception request for Renvela 0.8 gram powder packets. 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 submitted documentation does not contain medical records or a prescriber statement. A request for documentation was sent to the prescriber; however, no further information was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested promethazine with codeine 6.25/10-milligrams/5-milliliters to treat the enrollees cough due to coccidioidomycosis and possibly related to 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 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.Drugs prescribed for the symptomatic treatment of cough and colds are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 20 milligram tablets prescribed for the enrollees condition. 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.Xarelto 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.