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

The enrollee requested Prednisolone Acetate suspension 1% prescribed for unknown diagnosis. The Part D plan denied the additional reimbursement request.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 filled a prescription for Prednisolone Acetate suspension 1%, 30 day supply on April 1, 2021 and paid a copay of $12.00. A second prescription of the Prednisolone Acetate Suspension 1% was filled on April 7, 2021 and the enrollee was charged the member rate, based on 30-day supply refilled too soon. The plan will only reimburse up to the contracted price of the drug, minus any deductible, copay or coinsurance for a drug that is filled within the approved coverage period. We determined that the plan calculated the cost correctly and is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxychloroquine Sulfate 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. Hydroxychloroquine Sulfate  is a generic drug on Tier 3 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 Ofev 100-milligram capsule to treat interstitial lung disease secondary to Taxol-related pneumonitis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. The record shows you were prescribed Ofev 100-milligram capsule to treat interstitial lung disease secondary to Taxol-related pneumonitis. We asked the plan to send the complete copy of the case file. However, we did not receive the documentation.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. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 Eliquis 2.5 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 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 Prevymis 480 milligram tablets prescribed for cytomegalovirus prophylaxis in a heart transplant recipient. 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 indicates the prescriber ordered Prevymis for cytomegalovirus prophylaxis in a heart transplant recipient. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsule prescribed for non 24-hour sleep/wake disorder. We received a reconsideration 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. 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. Multiple attempts were made to request records by fax to a number verified by the office of the prescriber. We did not receive the documentation requested.The documentation shows Hetlioz was prescribed to treat non 24-hour sleep/wake 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 your appeal and determined that the plan is not required to cover Hetlioz. 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 Albuterol sulfate (2.5 milligram per 3 milliliters) 0.083% inhalation nebulization solution prescribed to treat asthma. The Part D Plan denied the appeal 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.The record shows Albuterol Sulfate is being administered through a nebulizer in the home setting. Medicare Part B may pay for 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 cover the Albuterol Sulfate. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for Mitomycin 5 milligram vial prescribed for conjunctival pigmentations and malignant melanoma. 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 Mitomycin was prescribed to treat conjunctival pigmentations and malignant melanoma. 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 Mitomycin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsule prescribed for circadian rhythm sleep disorder, free running type. We received a reconsideration 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. 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 documentation shows Hetlioz was prescribed to treat circadian rhythm sleep disorder, free running type. 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 your appeal and determined that the plan is not required to cover Hetlioz. 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 a tiering exception request for Azasite 1% ophthalmic solution prescribed for meibomian gland dysfunction right eye, upper and lower eyelids. 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. (It is noted that paperwork for patient financial assistance has been submitted at reconsideration; however, we are an independent review entity that does second level appeal reviews for Part D plan denials. We do not process forms for financial assistance. Please submit the paperwork to the correct organization).Azasite has been approved 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 the appeal and determined that the plan is not required to grant a lower-cost tiering exception for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Botox 100 unit reconstituted solution for injection prescribed for chronic migraine prophylaxis. 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 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. Botox is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colchicine 0.6 milligram tablet. 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. Colchicine 0.6 milligram tablet is a generic drug on Tier 3 of the plans formulary. We requested additional information from your prescriber but did not receive a response. The documentation does not support that all drugs available on lower tiers to treat your 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 Vyzulta 0.024% ophthalmic drops prescribed one drop both eyes every evening for glaucoma. 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 Vyzulta.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Forteo 620 microgram/2.48 milliliter prescribed for age-related osteoporosis. 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. We asked the prescriber to send us information regarding the medical records. 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.The documentation shows Forteo was prescribed to treat age-related osteoporosis. The plan requires for coverage of Forteo that the enrollee have post menopausal osteoporosis and a pre-treatment T-score of less than or equal to -2.5.  The medical records show a T score of -4.37 and post menopausal osteoporosis.The documentation includes clinical notes which satisfied the plan's coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xhance 93 microgram/actuation nasal spray prescribed for hypertrophy of nasal turbinates. 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.Xhance 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 for the enrollee's condition. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 9 milligram extended release tablets prescribed for ulcerative colitis. 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. Budesonide 9 milligram extended release tablets was prescribed to treat ulcerative colitis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation does not support the enrollee has met the plan's prior authorization criteria.  A physician reviewed your appeal and determined that the plan is not required to cover Budesonide. 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 a direct member reimbursement request for Farxiga 10 milligram tablets prescribed for the enrollees condition. 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.Farxiga is a brand drug on Tier 4 of the plans formulary. The prescriber submitted a supporting statement. The supporting statement did not address why all the drugs available on the lower tiers of the plans formulary would not work. 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.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nuplazid 34 milligram capsules prescribed for psychosis related to Parkinsons 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.The medical records, office note of July 15, 2021, validates that the prescriber ordered Nuplazid for psychosis related to Parkinsons disease. The Medicare approved compendia support the use of this drug for your condition.A physician reviewed the appeal and determined that the plan is required to cover Nuplazid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is NP Thyroid 90 milligram tablets to treat an enrollee with a thyroid problem. The Part D plan denied the appeal 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.The record shows the physician prescribed NP Thyroid 90 milligram tablets. However, the requested drug has not been approved by the United States Food and Drug Administration. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aubagio 14 milligram tablets prescribed to treat relapsing remitting multiple sclerosis. The Part D plan denied the appeal 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.Aubagio is not included in the plans formulary (list of covered drugs). 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 prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm.A physician reviewed the appeal and determined that the plan is not required to cover Aubagio 14 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 97 milligram-103 milligram tablet. 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. Entresto 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 a request for coverage of Combigan 0.2-0.5% ophthalmic solution prescribed for bilateral primary open-angle glaucoma. 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 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. Combigan is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Stelara 90 milligram/milliliter solution prefilled syringe prescribed as directed for hidradenitis suppurativa. 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 Stelara to treat your hidradenitis suppurativa. 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 Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Uro-MP 118 milligram capsules prescribed for cystitis. 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 determined that the plan is not required to cover Uro-MP because it is an over-the-counter product. Nonprescription or over-the-counter drugs are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Amphotericin B 50-milligram Vial for prevention of fungal keratitis. 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 Amphotericin B 50-milligram Vial for prevention of fungal keratitis. However, the Medicare approved compendia do not support the use of this drug for your condition. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.