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

You requested Budesonide 0.5 milligram/2 milliliter solution prescribed daily for asthma. 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. The record shows Budesonide was prescribed to treat asthma. The requested drug is being used via nebulizer. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Therefore, coverage under Part D is excluded for any drug for which payment would be available under Part B.We determined that the plan is not required to cover Budesonide. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Allopurinol 100 milligram tablet prescribed daily for gout. The Part D Plan denied your request for a 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 information submitted at the reconsideration level. We asked your prescriber to send us information about 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 similar medications on the lower tiers would not work for you. . However, we did not receive the documentation.Allopurinol is a generic drug on Tier 2 of the plans formulary. There are no generic 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 Levothyroxine Sodium 100 micrograms prescribed daily for hypothyroidism. The Part D Plan denied your request for a 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 information submitted at the reconsideration level. We asked your prescriber to send us information about 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 similar medications on the lower tiers would not work for you. . However, we did not receive the documentation.Levothyroxine Sodium is a generic drug on Tier 2 of the plans formulary. There are no generic 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 Budesonide 0.5 milligram/2 milliliter ampul-neb prescribed for asthma. The Part D plan denied your requestWe 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 Budesonide is being administered through a nebulizer for use in the home setting. Medicare Part B covers 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 reimburse for the Budesonide. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epclusa 400-100 milligram tablets prescribed as directed for hepatitis C. The Part D plan denied the 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 medical records show you were prescribed Epclusa for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has been met. 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 Epclusa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Carbidopa/Levodopa/Entacapone 37.5-150-200 milligram tablet to treat 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.We asked the prescriber to send us information regarding the enrollees condition. Specifically, we asked for records to show why other medications on the plan's lower tiers would not work for the enrollee. However, we did not receive the documentation.Carbidopa/Levodopa/Entacapone 37.5-150-200 milligram tablet is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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 Sildenafil Citrate 20 milligram tablets prescribed as 540 tablets per 90 days to treat pulmonary arterial hypertension. The Part D plan approved the prior authorization for Sildenafil 20 milligram tablets but did not make a timely decision for the quantity requested of 540 tablets per 90 days. 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 requested additional information from the prescriber to support the medical necessity of the amount of 540 tablets per 90 days versus the amount allowed by the plan of 90 tablets per 30 days. The prescriber did not respond. There was no indication of why the higher amount of tablets were required. A physician reviewed your appeal and determined that the plan is not required to cover more than 90 tablets per 30 days of Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed daily for circadian rhythm sleep disorder, free running type. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The records show Hetlioz was prescribed to treat circadian rhythm sleep disorder, free running type. The Medicare approved compendia do support the use of this drug for this condition. However, the plan requires prior authorization criteria be met before they will cover the drug. The documentation provided does not show you have satisfied the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz 20 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dayvigo 5 milligram tablets prescribed to treat primary insomnia. The Part D plan denied your request for a formulary exception. 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 regulations and Medicare approved compendia. The drug requested is not on the plans formulary. There are no medical records supporting that all alternative drugs on the plans formulary, to treat the same condition, have been tried. A physician reviewed your appeal and determined that the plan is not required to cover Dayvigo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Duloxetine HCl 60 milligram DR capsules prescribed three times daily for the enrollees condition. The Part D plan denied your 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.Duloxetine HCl is a generic drug on Tier 2 of the plans formulary. Your doctor did not submit a supporting statement. A request for a supporting statement to address all lower-tiered alternatives was sent to your doctor; no documentation was received. All generic drugs on lower tiers have not been tried. 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 Megestrol Acetate 40 milligrams/milliliter prescribed for abnormal weight loss. 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. The record shows Megestrol Acetate 40 milligrams/milliliter is prescribed to treat abnormal weight loss. We asked the prescriber to send us documentation regarding the enrollees hospice status. However, we did not receive the documentation. Medicare records indicate that the enrollee is currently in hospice for unspecified severe protein-calorie malnutrition (E43). The medication at issue is used to treat a condition related to the terminal illness. Therefore, this drug is eligible for Medicare Part A coverage, and cannot be covered under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the Megestrol Acetate 40 milligrams/milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benicar HCT 40-12.5 milligram tablet to treat 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.The prescriber states the formulary alternatives are contraindicated due to the enrollees additional diagnosis of chronic obstructive pulmonary disease. The Medicare-approved compendia do not support any contraindications. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Spiriva 18 microgram Handihaler prescribed twice a day to treat chronic obstructive lung disease. 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. Spiriva is a brand drug on Tier 3 of the plans formulary. There are no brand name drugs in the lower cost-sharing tiers to treat your 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 Repatha 140 milligram/1 milliliter syringe prescribed for familial hypercholesterolemia. The Part D plan denied your 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 physician did not submit a supporting statement. A request for a supporting statement was submitted; no documentation was received from your doctor. The documentation on file does not address all formulary alternatives were tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxycodone Hydrochloride Extended Release 15 milligram tablets prescribed to treat chronic pain. The Part D plan denied your request for a formulary exception. 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 regulations and Medicare approved compendia. The drug requested is not on the plans formulary. There are no medical records supporting that all alternative drugs on the plans formulary, to treat the same condition, have been tried. A physician reviewed your appeal and determined that the plan is not required to cover Oxycodone Hydrochloride.
Appeal type: Prescription Drug
Decision: Favorable

You requested Shingrix vaccine prescribed for shingles vaccination. The Part D plan denied your request.We received a 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 you received the Shingrix vaccine from your physician on July 24, 2020. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. According to your plan's Evidence of Coverage, 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 plans formulary shows the drug is covered as a Tier 3 drug. The documentation submitted includes a receipt indicating you paid for the vaccine and its administration fee in full. We determined that the plan is required to reimburse you for their share of the cost for the Shingrix vaccine and administration fee.
Appeal type: Prescription Drug
Decision: Favorable

You asked for reimbursement for a Shingrix injection. The Part D plan did not provide a timely redetermination decision. 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 information provided supports all requirements have been met for reimbursement of a Shingrix injection.A physician reviewed your appeal and determined that the plan is required to reimburse the amount of the Shingrix injection.
Appeal type: Prescription Drug
Decision: Favorable

You requested Shingrix vaccine prescribed for shingles vaccination. The Part D plan denied your request.We received a 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 you received the Shingrix vaccine from your physician on September 19, 2019. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. According to your plan's Evidence of Coverage, 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 plans formulary shows the drug is covered as a Tier 3 drug. The documentation submitted includes a receipt indicating you paid for the vaccine and its administration fee in full. We determined that the plan is required to reimburse you for their share of the cost for the Shingrix vaccine and administration fee.
Appeal type: Prescription Drug
Decision: Favorable

You requested Shingrix 50 micrograms  prescribed for shingles vaccination. The Part D plan denied your request.We received a case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The record shows you received the vaccination at a clinic. You provided a statement from the clinic showing you paid the full cost of the vaccine to your clinic. According to the plans Evidence of Coverage, the plan calculates reimbursement based on the total cost of the drug, minus your required co-payment amount (including administration), up to the plan limit.We determined that the plan is required to provide reimbursement for the Shingrix vaccine for their share of the cost, in accordance to the plans out of network rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Celecoxib 200 milligram capsules to treat pain in an enrollee with idiopathic peripheral neuropathy.   The Part D plan denied the request.  The requested 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 prescriber has not provided patient specific clinical rationale, supported by medical records, 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 formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Olmesartan-hydrochlorothiazide 40-12.5 milligram tablets prescribed for unknown diagnosis. The Part D plan denied your request.We received a case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. The record shows the Express Scripts discount was applied to the purchase because the insurance information was not up-to-date or not available. When your benefit card was used, you acknowledged and agreed that Express Scripts will be treated as the primary payor with respect to the medications that you have selected to purchase through the Express Scripts discount program. Therefore, the Plan is not required to cover or provide reimbursement for Olmesartan-hydrochlorothiazide.To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance without applying the Express Scripts discount.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Simvastatin 20 milligram tablets prescribed for unknown diagnosis. The Part D plan denied your request.We received a case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. The record shows the Express Scripts discount was applied to the purchase because the insurance information was not up-to-date or not available. When your benefit card was used, you acknowledged and agreed that Express Scripts will be treated as the primary payor with respect to the medications that you have selected to purchase through the Express Scripts discount program. Therefore, the Plan is not required to cover or provide reimbursement for Simvastatin.To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance without applying the Express Scripts discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amitiza 24-microgram capsule to treat opioid induced chronic constipation. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 provided patient specific clinical rationale, supported by medical records, 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 formulary 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 Synthroid 175 microgram tablets prescribed every other day for unspecified hypothyroidism. The Part D plan denied your 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. Synthroid 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. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception and reimbursement request for Albuterol Sulfate HFA 90 microgram inhaler to treat an unknown condition. 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. Albuterol Sulfate HFA is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met and reimbursement cannot be made.