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

At issue is Repatha Pushtronex System 420 milligram/3.5 milliliter solution prescribed for hyperlipidemia. 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 enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. However, we did not receive the documentation.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. 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. A physician reviewed your appeal and determined that the plan is not required to cover Repatha Pushtronex System.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Promethazine 25 milligram suppository prescribed for vomiting. 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 enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. However, we did not receive the documentation.The documentation shows the prescriber ordered Promethazine for unspecified vomiting. 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 Promethazine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lenvima (10-milligram Daily Dose) Capsule Therapeutic Pack to treat endometrial cancer. 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.A request was submitted to the prescriber to clarify the diagnosis and medical history, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  Relevant medical records were requested but not provided. At reconsideration, the diagnoses of radioactive iodine-refractory and unresectable, locally recurrent or metastatic disease, advanced or relapsed renal cell carcinoma, and advanced endometrial carcinoma were given. Additionally, the beneficiary is stated to have has radioiodine refractory disease. However, no medical records were provided by the prescriber to support whether the requested drug was being prescribed for a medically accepted indication. 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 Trelegy Ellipta 200-62.5-25 prescribed for persistent severe asthma. The case was auto-forwarded by the plan.  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 but did not get a response. In order to establish medical necessity and confirm that the requested drug is being used per the Food and Drug Administrations guidelines and per your plans criteria, additional information was required. The information was insufficient to fulfill these criterion. A physician reviewed your appeal and determined that the plan is not required to cover Trelegy Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Breo Ellipta 200-24 microgram prescribed for unknown diagnosis. The Part D plan denied the 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 documentation shows Breo Ellipta was billed as a self-administrable drug during an outpatient observation stay. The hospital invoice submitted does not show that the enrollee paid out of pocket for the medication received during the outpatient observation stay. According to the plan's Evidence of Coverage, if the enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The documentation submitted does not include a receipt showing the enrollee paid for the Breo Ellipta. We determined that the plan is required to reimburse you for their share of the cost for the Breo Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 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

At issue is Vyzulta 0.024% eye drops prescribed 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.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. 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. A physician reviewed your appeal and determined that the plan is not required to cover Vyzulta.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Wegovy 0.5 milligram/0.5 milliliter solution auto-injector prescribed to treat obesity. 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.The record shows you were prescribed Wegovy for the treatment of weight gain. We determined the plan is not required to cover Wegovy because it is excluded from coverage under Part D. If you purchased drugs/products that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug/product. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix vial kit. 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 biologic drug on Tier 4 of the plans formulary. There are no biologic 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 tiering exception request for Repatha Sureclick 140-milligrams/milliliter Pen Injector to treat mixed hyperlipidemia and atherosclerotic heart disease of native coronary artery without angina pectoris. 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.Repatha is a brand biologic drug on Tier 3 of the plans formulary. There are no brand biologic 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 Trintellix 10 milligram tablets prescribed for major depressive disorder. The Part D plan denied the request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Trintellix 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 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 a tiering exception request for Simbrinza 1-0.2% Ophthalmic Suspension to treat glaucoma and eye pressure. 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.Simbrinza 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Icosapent Ethyl 1 gram capsule prescribed for hyperlipidemia. 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 prescriber indicates Icosapent Ethyl is required due to the enrollee has diabetes mellitus, hypertension, and is a former smoker with a family history of heart disease. The prescriber also indicates the enrollee has elevated triglycerides above 150 milligram per deciliters. However, your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The prior authorization requirements have not been met. A physician reviewed your appeal and determined that the plan is not required to cover Icosapent Ethyl.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Ingrezza 40-milligram capsule to treat drug induced subacute dyskinesia. The case was auto-forwarded by 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.The documentation satisfies the plans 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 Copaxone 40 milligram/milliliter solution prescribed for multiple sclerosis. 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.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Copaxone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Lotemax SM 0.38% ophthalmic gel prescribed for recurrent iridocyclitis. 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 documentation shows the prescriber ordered Lotemax SM 0.38% ophthalmic gel for recurrent iridocyclitis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. Therefore, a tiering exception cannot be granted.A physician reviewed your appeal and determined that the plan is not required to cover Lotemax SM.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rhofade 1% cream 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: Favorable

At issue is Vraylar 1.5 milligram capsules prescribed as directed for bipolar disorder, current episode manic without psychotic features, unspecified. 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 also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Vraylar to treat your bipolar disorder, current episode manic without psychotic features, unspecified. The documentation submitted indicates that you tried and did not have success with ability. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Repatha pushtronex 420 milligram/3.5 milliliter prescribed for hyperlipidemia. 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. The documentation shows Repatha was prescribed for hyperlipidemia without clinical atherosclerotic cardiovascular disease. 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 Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantanoprost 0.005% ophthalmologic solution. 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. Lantanoprost 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

The enrollee requested Moxifloxacin HCL solution prescribed for unknown diagnosis. 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 shows the enrollee purchased Moxifloxacin HCL from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We determined the copay for Moxifloxaxin HCL was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Prednisolone 1% OP solution prescribed for unknown diagnosis. 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 shows the enrollee purchased Prednisolone from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We determined the copay for Prednisolone was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Prolensa 0.07% prescribed for unknown diagnosis. 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 shows the enrollee purchased Prolensa from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We determined the copay for Prolensa was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Muse 1000 microgram pellet prescribed for erectile dysfunction. The Part D plan denied the 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. We determined that the plan is not required to cover the Muse. Medicare excludes certain drugs from Part D coverage. Muse is an excluded drug when used to treat sexual or erectile dysfunction; or to treat a condition other than sexual or erectile dysfunction for which the drug has not been approved by the Food and Drug Administration. The record does not indicate that the plan provides supplemental coverage for Muse. Therefore, the plan is not required to cover it. 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 prior authorization request for Hetlioz 20 milligram capsules prescribed for non-24 hour sleep-wake disorder. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read the file carefully. We reviewed all documentation submitted. The documentation on hand does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Linzess 145 microgram capsules prescribed as directed for gastroesophageal reflux disease without esophagitis, injury of other intra-abdominal organs, and functional dyspepsia. 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 Linzess to treat your gastroesophageal reflux disease without esophagitis, injury of other intra-abdominal organs, and functional dyspepsia. 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 Linzess.