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

At issue is Repatha Sureclick Auto Injector 140 milligram/milliliter prescribed for hyperlipidemia, unspecified with atherosclerotic heart disease of native coronary artery without angina pectoris. 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. 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 does not indicate why the other alternative on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick Auto Injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dextroamphetamine-Amphetamine 25 milligram extended release capsule prescribed 120 tablets per 30 days for attention deficit hyperactivity 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber indicates that Dextroamphetamine-Amphetamine 25 milligram extended release 25 milligram capsule with a quantity of 120 capsules per 30 days is requested to treat attention deficit hyperactivity disorder. The prescriber indicates that 40 milligram capsules given twice a day had been approved and to please approve 50 milligram capsules to be given twice a day. However, the medication is to be given at the lowest dose or dispensed at the lowest amount in order to minimize the chance for overdose. The plan has a quantity limit of 60 capsules per 30 days. The documentation does not support a medical necessity for an exception to the plans quantity limit.  A physician reviewed your appeal and determined that the plan is not required to cover Dextroamphetamine-Amphetamine 25 milligram capsule with a quantity of 120 capsules per 30 days.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Eszopiclone 2 milligram tablet prescribed for insomnia. 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. 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 Eszopiclone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brilinta 90 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. Brilinta 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 a tiering exception request for Aimovig 140-milligrams/milliliter Solution Auto-Injector Subcutaneous to treat migraine headaches. 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.Aimovig 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 Lidocaine 5% Patch to treat low back pain and left hip pain status post unspecified fall, initial encounter. 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 use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. 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 Repatha 140 milligram/milliliter SureClick pen injector prescribed as directed for atherosclerosis of native coronary artery of native heart without angina pectoris. 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 Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 20 milligram tablets prescribed FREQUENCY. 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. Xarelto 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 Ajovy subcutaneous injection prescribed for chronic migraine. 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 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. 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 Ajovy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xhance 93 microgram nasal spray 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 a formulary exception request for Nucynta 50 milligram extended release tablets prescribed for shoulder pain status post shoulder replacement surgery. 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 requested additional documentation related to this case. Specifically, we asked the prescriber to submit medical records to support a covered diagnosis and a prescriber statement. We received a prescriber statement and included it in the review.The submitted documentation indicates the prescriber ordered Nucynta for shoulder pain status post shoulder replacement surgery. The enrollee will be taking the medication following the surgery as needed. 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 Repatha Sureclick Solution 140 milligram/milliliter auto-injector prescribed as directed for atherosclerotic heart disease of native coronary artery without angina pectoris. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. . 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 for you. A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lynparza 100 milligram tablets prescribed for metastatic cholangiocarcinoma, BRCA2 mutation. 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 Lynparza for metastatic cholangiocarcinoma, BRCA2 mutation. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There are no Medicare approved journal articles to support the use of Lynparza 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 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 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 requested additional information from the prescriber. Specifically, we requested a prescriber statement to support the enrollee met the plans prior authorization coverage criteria. However, we did not receive the requested information.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

The enrollee requested Albuterol sulfate 2.5 milligram/3 milliliter vial prescribed for chronic obstructive pulmonary 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 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 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 Albuterol sulfate. Please submit your 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: Favorable

At issue is Tacrolimus 0.5 milligram capsule prescribed for a kidney transplant recipient. 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. Medicare systems show the kidney transplant was not a Medicare Part A covered procedure. The enrollee had a transplant on July 11, 1985, that failed August 14, 2005. A second transplant was done on August 15, 2005, but Part A had terminated on July 31, 1988, and entitlement did not begin again until March 1, 2020. This drug is eligible under Part D drug benefits. Medicare approved compendia supports the use of this drug for the reported condition.  A physician reviewed your appeal and determined that the plan is required to cover Tacrolimus 0.5 milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Armour Thyroid 30 milligram prescribed daily for hyperthyroidism. The Part D plan denied the enrollees 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 determined that the plan is not required to cover the Armour Thyroid. According to Microdex, Armour Thyroid has not been found by the Food and Drug Administration to be safe and effective; and the drug product label has not been approved. Therefore, the drug is excluded from coverage under Medicare Part D. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent patch prescribed as directed for polyneuropathy, 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 information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The documentation shows your doctor prescribed Lidocaine 5 percent patch to treat your polyneuropathy, unspecified. 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 Lidocaine 5 percent patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 10 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. Farxiga is a brand 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: Unfavorable

The enrollee requested Atorvastatin 40 milligram tablet. 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. The record shows the enrollee received Atorvastatin as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay 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 enrollee provided a hospital statement and receipt showing payment was made for the drugs. The National Drug Code provided has been verified with the Food and Drug Administration as a valid code. However, the prescribers name and National Provider Identifier (NPI) number of the prescriber is missing. Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Carvedilol 3.125 milligram tablet. 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. The record shows the enrollee received Carvedilol as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay 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 enrollee provided a hospital statement and receipt showing payment was made for the drugs. The National Drug Code provided has been verified with the Food and Drug Administration as a valid code. However, the prescribers name and National Provider Identifier (NPI) number of the prescriber is missing. Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Clopidogrel 75 milligram tablet. 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. The record shows the enrollee received Clopidogrel as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay 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 enrollee provided a hospital statement and receipt showing payment was made for the drugs. The National Drug Code provided has been verified with the Food and Drug Administration as a valid code. However, the prescribers name and National Provider Identifier (NPI) number of the prescriber is missing. Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Doxazosin 4 milligram tablet. 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. The record shows the enrollee received Doxazosin as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay 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 enrollee provided a hospital statement and receipt showing payment was made for the drugs. The National Drug Code provided has been verified with the Food and Drug Administration as a valid code. However, the prescribers name and National Provider Identifier (NPI) number of the prescriber is missing. Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Finasteride 5 milligram tablet. 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. The record shows the enrollee received Finasteride as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay 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 enrollee provided a hospital statement and receipt showing payment was made for the drugs. The National Drug Code provided has been verified with the Food and Drug Administration as a valid code. However, the prescribers name and National Provider Identifier (NPI) number of the prescriber is missing. Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.