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

At issue is Fluorometholone 0.1% suspension prescribed as 10 per 75 days for the diagnosis of glaucoma. The Part D Plan denied your request for a tiering exception because the requested drug is on the lowest cost-sharing tier allowed by the plan. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and reviewed the plans enrollment data available. The prescriber states that the enrollee has been on this generic option drug and it has been working and she must be on a steroid that is low risk to causing intraocular pressure spikes. However, the drug is already being provided at the lowest cost-sharing amount allowed by the plan. Fluorometholone is a generic drug on Tier 3 of the plans formulary. There are no 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 Reviewers opinion is that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Viibryd 40 milligrams prescribed as directed for major depressive disorder. The Part D plan denied your request for a tiering exception. We received a standard reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The record shows you were prescribed the Viibryd for major depressive disorder. 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 cover the Viibryd.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested lidocaine 5% patch prescribed for unilateral primary arthritis of knees and other specific arthropathies not elsewhere classified. The Part D plan denied your request because the diagnosis is not a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation supports your doctor prescribed the lidocaine 5% patch to treat your unilateral primary arthritis of knees and other specific arthropathies not elsewhere classified. 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 the lidocaine 5% patch. This medication has not been medically approved for your diagnosis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Orilissa 200 milligrams prescribed twice daily for thoracic endometriosis. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your physician submitted a supporting statement and medical records. The medical records show the physician had prescribed Orilissa 200 milligrams to treat your thoracic endometriosis. The Medicare approved compendium supports the use of the requested drug for your condition.However, the records do not show why you cannot take other drugs on your plans formulary for your condition. Specifically, the physician submitted a prescriber statement that does not indicate you have tried all alternative drugs to treat your thoracic endometriosis. Your medical records do not show that all alternative drugs on the plan formulary have been tried or why you cannot take them. Therefore, the plan is not required to grant an off-formulary exception for the Orilissa 200 milligrams. A physician reviewed your appeal and determined that the plan is not required to cover Orilissa 200 milligrams because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligrams prescribed twice daily for familial hypercholesterolemia. The Part D Plan denied your request for a tiering exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Repatha is a brand drug on Tier 3 of the plans formulary. The prescriber statement shows you were being treated for familial hypercholesterolemia and mixed hyperlipidemia. Your doctor stated that you tried taking statin with no effect and due to your strong family history of cardiovascular disease you should continue on Repatha. However, there are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception. There are no lower tiered brand drugs of the same type to treat your 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 Sirolimus 0.5 milligram tablet to treat post liver transplant.  The Part D plan denied the request stating that the provided diagnosis is not a medically accepted indication.  We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.  The use of the requested drug to treat the provided diagnosis is not a medically accepted indication. The documentation does not support you are rejecting your transplanted liver.  The Medicare approved compendia does not contain any citations to support the use of the requested drug, as prescribed, for stable transplant status without rejection.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.  The following citation in AHFS-DI, a Medicare approved compendium, states:  'Although sirolimus has been used for the prevention of rejection of liver allografts, the manufacturer states that safety and efficacy of the drug as immunosuppressive therapy have not been established in liver transplant patients and that such use is therefore not recommended.Ref Wyeth Pharmaceuticals Inc. Rapamune (sirolimus) oral solution and tablets prescribing information. Philadelphia, PA; 2010 Dec.'  A physician reviewed your appeal and determined that the plan is not required to cover Sirolimus. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Eliquis 5 milligrams prescribed daily for atrial fibrillation. The Part D plan denied your request for a tiering exception because Eliquis is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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 also researched Medicare systems and reviewed the enrollment data available. The record shows Eliquis is being prescribed for atrial fibrillation. The Medicare approved compendia supports the use of the requested drug for your condition. The plan shows Eliquis is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cresemba 186 milligram capsules prescribed as directed for the prevention of fungal infections in an enrollee with acute myeloid leukemia and neutropenia. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records show the enrollee has acute myeloid leukemia and neutropenia. The doctor prescribed Cresemba to prevent fungal infections. However, the Medicare approved compendia do not support the use of Cresemba for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Enbrel 50 milligrams for psoriasis. The Part D Plan denied your request for a tiering exception because drugs on specialty tiers are excluded from tier exceptions. 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.Enbrel is a brand drug on specialty tier of the plans formulary. The prescriber statement shows the drug is ordered for the enrollees psoriasis and joint pain. Specialty tier drugs are not eligible for tiering exceptions.    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 Gralise Extended Release, 600 milligrams prescribed one tablet daily for chronic neck pain. The plan denied the appeal because the National Drug Code number submitted for this drug indicates it is not a Food Drug Administration approved drug. 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. Your medical records show Gralise Extended Release is being prescribed for chronic neck pain. The National Drug Code Directory does not list Gralise Extended Release. Additionally, this drug is not listed in your plans formulary. Therefore, the requested drug is not eligible for coverage under your Part D plan.A physician reviewed your appeal and determined that the plan is not required to cover Gralise Extended Release because it is not listed in the National Drug Code Directory or on your plans formulary.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Androderm 4 milligrams per 24 hours patch prescribed as directed for hypogonadotropic hypogonadism. The Part D plan denied your request because the drug you requested is not included on your plans formulary. We received a reconsideration request.We performed an independent and de novo review. 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 that your doctor prescribed Androderm to treat your hypogonadotropic hypogonadism. The Medicare approved compendium supports the use of this drug to treat your condition. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Androderm.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is an Anoro Ellipta 62.5-25 microgram inhaler. The Part D plan denied your request for a tiering exception because the drug had already been approved for a non-formulary exception and therefore, a tiering exception could not be made. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare law and the plans rules.The documentation in the record shows that Anoro Ellipta is covered for the enrollee through a formulary exception. Medicare law and plan rules do not allow tiering exceptions for non-formulary drugs being covered through a formulary exception. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover a tiering exception for Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benzonatate, 200-milligram capsule for chronic cough and asthma. The Part D plan denied the request because the plan's Medicare Part D drug plan cannot cover drugs used for the treatment of the symptoms of cough or cold. Medicare does not cover drugs for treatment of symptoms of a cough or cold. 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. Your plan denied the request for coverage of Benzonatate because your Medicare Part D drug plan cannot cover drugs for the treatment of symptoms of a cough or cold. Medicare excludes these drugs from coverage. A physician reviewed your appeal and determined that the plan is not required to cover Benzonatate because the drug does not meet the definition of a Part D drug per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Fycompa 10 milligram tablet to treat epilepsy. 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 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.Fycompa is a brand drug on Tier 5 of the plans formulary. Tier 5 is a specialty tier. Specialty tiers are not eligible for tiering exceptions. 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 Repatha Solution Autoinjector, 140 mg/ml, 2 autoinjectors per 30 days, for hyperlipidemia in an enrollee with atherosclerotic cardiovascular disease.   The Part D Plan denied the request.  We received a reconsideration request. in an enrollee with atherosclerotic cardiovascular disease.   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 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 has not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plans coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is reimbursement of Bystolic 5 milligram tablets for a total of 12 tablets. Upon review, the Part D Plan denied coverage stating it was too soon to fill the prescription. Subsequently, the Part D Qualified Independent Contractor (QIC) received a retrospective reconsideration request. Costs for covered Part D drugs are treated as incurred only if they were paid by the individual (or by another person, such as a family member, on behalf of the individual), paid by CMS on behalf of a low-income subsidy-eligible individual, or paid under a qualified entity such as SPAP, acquired immune deficiency syndrome (AIDS) Drug Assistance Program (ADAP), or a bona fide charity as defined in CMS regulations. The Part D QIC conducted an independent and de novo review of this request for coverage. The QIC reviewed all documentation submitted for review, including the case file from the Plan, and any information submitted at the reconsideration level. The documentation shows the enrollee went on vacation and forgot medications. The pharmacy provided the necessary drugs per the enrollees physicians phone call, consisting of 12 Bystolic 5 milligram tablets. The enrollee submitted documentation including the reimbursement form and receipts of amounts paid. The documentation from the plan includes a vacation override approval from the plan. In this instance, the QIC has determined that reimbursement can be allowed for the 12 tablets of Bystolic. In conclusion, the decision of the QIC is favorable.
Appeal type: Prescription Drug
Decision: Favorable

At issue is reimbursement of Eliquis 5 milligram tablets for a total of 8 tablets. Upon review, the Part D Plan denied coverage stating it was too soon to fill the prescription. Subsequently, the Part D Qualified Independent Contractor (QIC) received a retrospective reconsideration request. Costs for covered Part D drugs are treated as incurred only if they were paid by the individual (or by another person, such as a family member, on behalf of the individual), paid by CMS on behalf of a low-income subsidy-eligible individual, or paid under a qualified entity such as SPAP, acquired immune deficiency syndrome (AIDS) Drug Assistance Program (ADAP), or a bona fide charity as defined in CMS regulations. The Part D QIC conducted an independent and de novo review of this request for coverage. The QIC reviewed all documentation submitted for review, including the case file from the Plan, and any information submitted at the reconsideration level. The documentation shows the enrollee went on vacation and forgot medications. The pharmacy provided the necessary drugs per the enrollees physicians phone call, consisting of 8 Eliquis tablets. The enrollee submitted documentation including the reimbursement form and receipts of amounts paid. The documentation from the plan includes a vacation override approval from the plan. In this instance, the QIC has determined that reimbursement can be allowed for the 8 tablets of Eliquis. In conclusion, the decision of the QIC is favorable.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement of Flecaininde Acetate 150 milligram tablets and a total of 8 tablets. Upon review, the Part D Plan denied coverage stating it was too soon to fill the prescription. Subsequently, the Part D Qualified Independent Contractor (QIC) received a retrospective reconsideration request. Costs for covered Part D drugs are treated as incurred only if they were paid by the individual (or by another person, such as a family member, on behalf of the individual), paid by CMS on behalf of a low-income subsidy-eligible individual, or paid under a qualified entity such as SPAP, acquired immune deficiency syndrome (AIDS) Drug Assistance Program (ADAP), or a bona fide charity as defined in CMS regulations. The Part D QIC conducted an independent and de novo review of this request for coverage. The QIC reviewed all documentation submitted for review, including the case file from the Plan, and any information submitted at the reconsideration level. The documentation shows the enrollee went on vacation and forgot medications. The pharmacy provided the necessary drugs per the enrollees physicians phone call, consisting of 8 Flecainide Acetate tablets. The enrollee submitted documentation including the reimbursement form and receipts of amounts paid. The documentation from the plan includes a vacation override approval from the plan. However, the plan has already approved this reimbursement. In this instance, the QIC has determined that reimbursement has been approved previously.  In conclusion, the decision of the QIC is unfavorable.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Atovaquone Suspension 750 milligrams/5 milliliters.  The Part D plan denied the request because your plan does not allow you to receive drugs in this tier at a lower cost share.  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.This drug is being provided by your plan at the cost sharing level of the Specialty Tier. Specialty Tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mupirocin Powder Bulk. 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 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.Drugs that are not covered by the Food and Drug Administration, such as the drug requested are excluded from Medicare Part D coverage. Therefore, the drug cannot be considered for reimbursement under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to reimburse the Mupirocin Powder Bulk because it is an excluded drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Glatiramer Acetate 40 milligrams/milliliter to treat relapsing Multiple Sclerosis. 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 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 the reconsideration appeal the prescriber submitted a statement clarifying the diagnosis and stating that the drug was not being used to treat a clinically isolated syndrome.  The enrollee satisfies the plans coverage criteria.  A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.