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

At issue is Lidocaine 5% topical patches prescribed as directed. You requested that the plan provide coverage for a drug that has prior authorization criteria. The plan did not make a decision within the required timeframe. We received an auto-forwarded reconsideration request from the plan.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. We asked the prescriber to send us a prescriber statement and medical records to show why the enrollee needs this medication. We did not receive the documentation requested.The documentation available for review does not include a prescriber statement or medical records. It is not known why the enrollee is receiving this medication. Therefore, it cannot be determined if the Medicare approved compendia support the use of this drug for the enrollees condition. Additionally, there is insufficient documentation to 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 Lidocaine patches.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Promacta 50 milligrams prescribed for thrombocytopenia due to chemotherapy. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Promacta 50 milligrams to treat your thrombocytopenia due to chemotherapy. However, the Medicare approved compendia do not support the use of this drug for your condition. In addition, the plan has prior authorization coverage criteria that are not satisfied by the records provided. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and determined  that the plan is not required to cover Promacta 50 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Vemlidy (Tenofovir Alafenamide Fumarate) 25 milligrams prescribed one tablet daily to treat Human Immunodeficiency Virus. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 following citation in AHFS-DI, a Medicare approved compendium, supports the use of the requested drug for the enrollees condition: Tenofovir Alafenamide Fumarate also is used for the treatment of Human Immunodeficiency Virus (HIV) infection. Tenofovir Diphosphate is active against hepatitis B virus (HBV) and Human Immunodeficiency Virus type-1 (HIV-1) and has some in vitro activity against HIV-2. The prescriber provided medical records, which document that the enrollee has HIV-1. Therefore, the requested drug is being prescribed for a medically accepted indication as defined by Medicare law.The documentation does not satisfy the plans coverage criteria.  The plans coverage criteria requires a Food and Drug Administration approved indication. However, treatment of Human Immunodeficiency Virus infection is a non-Food and Drug Administration use, supported by the Medicare compendium. Therefore, an exception to the plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that Vemlidy is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tymlos 80 microgram dose pen injector prescribed for postmenopausal osteoporosis. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 plan requires your physician to indicate why the formulary drugs would not be as effective as the requested drug and/or that the enrollee would have adverse effects before they will cover the requested Tymlos. Your medical records show your doctor prescribed Tymlos for your postmenopausal osteoporosis. A Medicare approved compendium does support the use of the requested drug for your condition. However, your doctor did not explain why the requested Tymlos is preferred over the plans current covered formulary drugs used to treat your condition. There is no indication your doctor has tried you on covered formulary drugs with documentation of the results or if the drugs would likely cause adverse events and/or would be less effective than the off-formulary drug Tymlos.A physician reviewed your appeal and determined that the plan is not required to cover Tymlos because the medical records do not indicate why the off-formulary drug is preferred over current drugs on the plans formulary to treat your condition.
Appeal type: Prescription Drug
Decision: Favorable

You requested Trulance 3 milligram tablets prescribed as directed for chronic idiopathic constipation. The Part D plan denied your request for a formulary exception 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 medical records submitted at reconsideration show the doctor prescribed Trulance for chronic idiopathic constipation. The Medicare approved compendium does support the use of this drug for the enrollees condition. Trulance is a drug on Tier 3 of the plans formulary. The plan has established prior authorization criteria for Trulance. The enrollee has satisfied the prior authorization criteria that the drug is prescribed for a Food and Drug Administration-approved indication. The plan has not imposed step therapy or quantity limit medications on this drug. A physician reviewed your appeal and determined that the plan is required to cover Trulance.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Intrarosa 6.5 milligram vaginal insert to treat unspecified postmenopausal symptoms. The Part D plan denied the request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vascepa 1 gram capsule prescribed for mixed hyperlipidemia. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. 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 submitted documentation indicates your doctor prescribed Vascepa for mixed hyperlipidemia. 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: Unfavorable

You requested Calcitriol 0.25 microgram capsules prescribed daily for secondary hyperparathyroidism caused by end-stage renal disease. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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. Medicare records show you had a kidney transplant November 16, 2020, that was covered under Medicare part A., This drug requested is therefore eligible for coverage under Medicare Part B. A drug prescribed for a Part D eligible individual cannot be considered a covered Part D drug if payment for the drug is available under Medicare Part A or B for that individual (as prescribed and dispensed or administered for the individual).We determined that the plan is not required to cover Calcitriol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception from your Part D Plan for Invokana, 300 milligram tablets. The Part D Plan denied your request for a tiering exception because there were no other similar drugs on a lower cost-sharing tier. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Invokana at a lower cost tier.Invokana is a brand name drug on Tier 3 of the plans formulary. There are no brand name drugs of the same type on the lower cost sharing tiers. If there are no brand name drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. Therefore, a tiering exception cannot be granted for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception from your Part D Plan for Trulicity, 0.75 milligram per 0.5 milliliter subcutaneous injection pen. The Part D Plan denied your request for a tiering exception because there were no other similar drugs on a lower cost-sharing tier. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Trulicity at a lower cost tier.Trulicity is a biologic brand name drug on Tier 3 of the plans formulary. There are no biologic brand name drugs of the same type on the lower cost sharing tiers. If there are no biologic brand name drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. Therefore, a tiering exception cannot be granted for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement of payment for Nasal Ointment prescribed for prevention of nose bleeds. The Part D plan denied the request. We received an expedited reconsideration request. We performed and 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 regulations and Medicare approved compendia. The reimbursement form does not have a valid National Drug Code. The pharmacy states the compound was not made there and is not billed as a compound. However, without a valid National Drug Code or compound ingredients, it cannot be determined if the Nasal Ointment is eligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to reimburse you for the Nasal Ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil citrate Tablet 25 milligram to treat male erectile dysfunction unspecified. The Part D plan denied the request. We received an auto-forwarded reconsideration request from the plan. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, 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 Octreotide Acetate 200 microgram/milliliter to treat post-surgical dumping syndrome. 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.Octreotide Acetate 200 microgram/milliliter is a generic drug on tier 4 of the plans formulary. There are no generic 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

At issue is Shingles Vaccine. The Part D plan denied the request because out-of-network rules were not met. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The record shows the enrollee was given the Shingles Vaccine at a non-network provider. The enrollee submitted a reimbursement form and a bill for the vaccine. However, the documentation does not include proof of payment.We determined that the plan is not required to reimburse you for the Shingles Vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ciclopirox 1% shampoo to treat skin flaking.  Medical records included indicate the scalp complaints are secondary to seborrheic dermatitis. The case was auto-forwarded from the plan.  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 prescriber has not indicated 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 formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec orally disintegrating/rapid dissolving tablets, 75 milligrams, to treat occipital neuritis. The Part D plan denied the request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The 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 Cevimeline hydrochloride 30 milligram capsules to treat sicca syndrome, unspecified. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has not indicated 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 formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Toremifene citrate 60 milligram tablets prescribed as directed for an enrollee with breast cancer. The Part D plan denied your request for a tiering exception. 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. Toremifene citrate is a generic drug on Tier 5, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the specialty tier from the tiering exception process. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Toremifene citrate. A tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxtellar XR 600 milligram tablets prescribed as directed. The Part D plan denied your request for a tiering exception. 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. Oxtellar XR is a brand drug on Tier 4, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the specialty tier from the tiering exception process. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover the drug. A tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta inhaler prescribed for chronic obstructive pulmonary disease. The Part D plan auto-forwarded this case.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.Anoro Ellipta inhaler is a brand drug on Tier 3 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 a Repatha SureClick 140 milligram/milliliter autoinjector pen prescribed for an enrollee with coronary artery disease and hypercholesterolemia. The Part D plan denied your request because the documentation did not support an off-formulary 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 information submitted at the reconsideration level. The records show the enrollee is intolerant of statin therapy. However, the documentation does not show why the enrollee cannot take a different drug on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 600 micrograms/2.4 milliliters (250 micrograms/milliliter) subcutaneous injection prescribed for osteoporosis. The Part D plan denied your request for a tiering exception because there were no brand drugs of the same type on the lower cost sharing tiers. 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. Forteo 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

You requested Carisoprodol 350 milligram tablets prescribed as directed for chronic pain. The Part D plan denied your request for a formulary exception 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 prescriber statement shows the doctor prescribed Carisoprodol for a chronic pain condition. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Carisoprodol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chantix starting month pack 0.5 milligrams (11 tablets) and 1 milligram (42 tablets) prescribed twice daily for smoking sensation. The Part D Plan denied your request for a tiering exception. 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.Chantix is a brand drug on Tier 4 of the plans formulary. However, 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 a tiering exception.