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

At issue is Lidocaine 5% patch. 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.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.Lidocaine 5% patch is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

You requested Cinacalcet HCL 20 milligram tablets prescribed for hyperparathyroidism. The Part D plan denied your request because the requested drug is dialysis related and bundles into payment that Medicare pays to dialysis centers under Medicare Part B.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 received the documentation and included it in our review.Your medical records show you received a kidney transplant and no longer required dialysis. Your doctor prescribed Cinacalcet for hyperparathyroidism. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: FDA uses for Cinacalcet HCL include primary hyperparathyroidism.A physician reviewed your appeal and determined that the plan is required to cover Cinacalcet HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Vraylar 3 milligram capsules prescribed for bipolar 1 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 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. Vraylar is included in Tier 5 of the plans formulary. Tier 5 of the plans formulary is the tier reserved for specialty drugs. The plan does not grant tiering exceptions for specialty drugs. Therefore, this drug is not eligible for coverage at a lower-cost tier. 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

At issue is a request for coverage of Lidocaine 5% ointment.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. The documentation indicates that Lidocaine 5% ointment has been prescribed for chronic pain of multiple sites including the lower back, hips, neck, and multiple joints. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the Lidocaine 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Velphoro 500 milligram tablet prescribed for an unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. According to Medicare rules, the requested drug cannot be approved for separate payment under Part D when it is for treatment on a patient who is receiving dialysis. Medicare records show the enrollee is actively receiving dialysis. Therefore, the Velphoro must be billed by the renal dialysis facility. We determined that the plan is not required to cover the Velphoro. Please submit your request for this drug through the dialysis provider.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a 56-day supply of Oxervate 0.002% eye drops prescribed for neurotrophic keratitis. The Part D plan denied your request.The documentation shows that a non-formulary exception was approved for a 30-day supply of Oxervate. Your medical records show your doctor prescribed Oxervate for neurotrophic keratitis. However, Oxervate is considered a specialty drug and the plan limits specialty drugs to a 30-day supply. A physician reviewed your appeal and determined that the plan is not required to cover the additional 26-day supply of Oxervate, as the daily drug supply exceeds the number of days that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Jakafi oral tablets. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Jakafi has been prescribed for myeloid neoplasm, myelodysplastic syndrome/myeloproliferative syndrome, unclassified with presence of the JAK2V617 mutation. The prescriber has noted that Jakafi will be given in combination with Azacitidine. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed the appeal and determined that the plan is not required to cover Jakafi.
Appeal type: Prescription Drug
Decision: Favorable

You requested Hydrocodone/Acetaminophen 10/325 milligram tablets (180 tablets per 30 days) prescribed every four hours as need for pain.We received the case to perform an independent and de novo review. 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 this medication. We received the documentation and included it in our review.Your medical records show your doctor prescribed Hydrocodone/Acetaminophen to treat your pain. The plan limits the amount of Hydrocodone/Acetaminophen 10/325 milligram tablets to180 tablets per 30 days. The requested quantity is within the plans allowed quantity limit.  Our physician reviewer's opinion is that quantity limit criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rosacea triple cream prescribed for unknown diagnosis.  We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The record shows the Rosacea triple cream is a compounded drug and each ingredient is reviewed individually. Medicare Part D does not cover non-prescription drugs. Some of the ingredients within the compounded drug are over-the-counter drugs and are not eligible for Part D coverage. We also found that the National Drug Codes submitted for each of the active ingredients are not listed with the Food and Drug Administration as valid codes. Therefore, we determined the plan is not required to cover the compounded drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix vial kit prescribed as directed. 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. Shingrix vial kit  is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dificid 200 milligram tablets prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is included on Tier 5 of the plans formulary. This Tier is identified as a Specialty Tier. The plan is not required to grant a tier exception for drugs available on their Specialty Tier. Therefore, a tier exception cannot be considered.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix 50 microgram/0.5 kit prescribed for shingles vaccination. The Part D plan did not make a 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 record states you received the Shingrix vaccine at your physicians office. Payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or provider's office. You submitted documentation to the plan that includes a payment record. However, the record does not include an itemized statement or receipt showing the payment was for the Shingrix vaccine. We determined that the plan is not required to reimburse you for the vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Enbrel Sureclick 50 milligram/milliliter auto-injector prescribed for rheumatoid arthritis. The Part D plan denied coverage.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 documentation on file did not include a supporting statement or medical records. A request for information was sent to your physician. Medical records and a physician supporting statement were received. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis 0.05 percent droperette prescribed as directed. 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.Restasis 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

At issue is Combigan 0.25-0.5% eye drops 20 milliliters per 90 days. 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 amount of the medication. We did not receive the documentation requested.Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. An exception to the plans quantity limit is not further considered.A physician reviewed your appeal and determined that the plan is not required to cover Combigan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Contrave 8/90 milligram 12-hour extended release tablets prescribed for weight loss. 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 records submitted at the reconsideration level. Drugs when used for weight loss are excluded from the Part D benefit. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligram prescribed at night for insomnia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your doctor prescribed Zolpidem Tartrate to treat your insomnia. Your 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 your appeal and determined that the plan is not required to cover Zolpidem Tartrate. Your physician has stated that you have not tried, nor do you have a contraindication to the alternative doxepin. This is a prior authorization requirement of your plan. 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

You requested Betahistine Hydrochloride Powder prescribed daily for vertigo. 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 levelThe plan denied your request for reimbursement because none of the ingredients of the compounded drug meets the definition of a Part D drug. Therefore, the compounded drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to cover the compounded drug Betahistine Hydrochloride Powder.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acyclovir 5 percent ointment prescribed as directed. 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 Shingrix 50 microgram/0.5milliliter prescribed as directed 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.Shingrix is a biological product drug on Tier 3 of the plans formulary. There are no biological product 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 Humira 40 milligram per 0.8 milliliter syringe prescribed for dissecting cellulitis of the scalp. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Humira to treat your dissecting cellulitis of the scalp. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Invega Sustenna 156 milligram/milliliter syringe prescribed 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.Invega Sustenna is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier 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

You requested a tiering exception for Neupro 2 milligram per 24 hour patch. 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.Neupro is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat your condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Neupro at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tramadol Hydrochloride 50 milligram prescribed three times daily as needed for low back pain. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. Your medical records show your doctor prescribed Tramadol Hydrochloride to treat your low back pain. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided supports the enrollee has satisfied the plan's coverage criteria.The medical documentation supports the pain is severe enough to require daily, around the clock, long-term opioid treatment and the enrollee is not opioid naive. In addition, your doctor has documented the ineffectiveness of non-opiate alternatives and has reviewed the state Prescription Drug Monitoring Program. Lastly, you have been counseled on the potential adverse effects of opioid analgesics. A physician reviewed your appeal and determined that the plan is required to cover Tramadol Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligrams/2 milliliter injection prescribed as directed for moderate to severe atopic dermatitis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 10 milligram tablets prescribed as directed. 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.Jardiance 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 Contrave ER 8 milligram-90 milligram tablets for morbid obesity. 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.We determined that the plan is not required to cover Contrave ER because it was prescribed for weight loss. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.