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

You asked the Plan to cover Calcipotriene 0.005% Cream. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Calcipotriene 0.005% Cream. The drug is requested to treat Grover's disease (transient and persistent acantholytic dermatosis), which is an off-label (non-FDA approved) use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Calcipotriene 0.005% Cream for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Calcipotriene 0.005% Cream. This decision does not concern the medical necessity 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 asked the Plan to provide a tiering exception for Dorzolamide-Timolol solution and Latanoprost solution. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for a tiering exception for Dorzolamide-Timolol and Latanoprost. Dorzolamide-Timolol solution and Latanoprost solution are requested to treat the enrollee's condition. The requested drugs are both on tier 2 of the Plan's formulary. There are no available lower tier drugs on the Plan's formulary to treat the enrollee's condition. Therefore, these drugs are not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition. Therefore, our decision is the Plan is not required to provide a tiering exception for Dorzolamide-Timolol solution and Latanoprost solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Alprazolam. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for a tiering exception for Alprazolam. The drug is requested to treat anxiety and panic disorders. Alprazolam is a generic drug on tier 2 of the Plan's formulary. There are no available lower tier generic drugs of the same type on the Plan's formulary to treat the enrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition. Therefore, our decision is the Plan is not required to provide a tiering exception for Alprazolam.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Praluent. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Praluent. Praluent was requested May 29, 2019 for ongoing treatment of hyperlipidemia in this enrollee with well documented atherosclerotic cardiovascular disease and statin intolerance who had been stabilized on Praluent. Repatha is on the Plan's formulary. 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 Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Praluent.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Aimovig. The Plan did not grant this request. We received this case to conduct an independent review.We asked a Physician Reviewer to determine whether the Plan was correct in denying the request for Aimovig which is subject to prior approval. Our Physician Reviewer needed additional information from you to make this determination. You were asked to address whether the drugs offered by the Plan for the treatment of the enrollee's condition would: (1) not be as effective as the requested drug; and/or (2) have adverse effects. The requested information was not received. Based on a review of the available documentation, neither prior authorization criteria nor prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is not required to cover Aimovig.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover the administration fee of Tenivac Vaccine administered on July 23, 2019 atyour physician's office. The Plan did not grant this request. We received this case to conduct anindependent review.The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances.In this case, you submitted a request for reimbursement along with a copy of paid receipt for theadministration fee of Tenivac Vaccine administered on July 23, 2019 at your physician's office. The Plandenied reimbursement of the administration fee stating this was covered under Medicare Part A/B,however, Tenivac Vaccine is a Medicare Part D drug on Tier 3 of the Plan's 2019 formulary. The Plan'sout-of-network coverage rules were followed. Therefore, our decision is the Plan is required to providecoverage and applicable reimbursement for the administration fee for Tenivac Vaccine administered onJuly 23, 2019 at your physician's office.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Aimovig 70 mg/mL. The Plan did not grant this request. We received this caseto conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Aimovig 70mg/ml.Aimovig 70mg/ml is requested for ongoing treatment of migraine headaches. There is no case file availablefor this medical review; however the Plan's appeal denial letter included the request for reconsideration.Coverage of Aimovig 70mg/ml was denied because there was insufficient documentation of a decrease inheadache frequency with Aimovig. You state that while being treated with Aimovig, the enrollee had areduction in migraine headaches by over 50%. However due to the delay in treatment related to lack of thePlan's approval for coverage of Aimovig, the enrollee is beginning to have intense headaches on a dailybasis. Medical records submitted with the request for reconsideration document the positive response toAimovig with a decrease in headache frequency from multiple per week to a maximum of four migrainesper month. The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion is that priorauthorization criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs.Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria aremet. Therefore, our decision is the Plan is required to cover Aimovig 70 mg/mL.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Humalog. The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Humalog.Humalog is requested for ongoing treatment of type II diabetes mellitus. The Plan has listed their formularyalternatives in their denial letter. The prescriber has not indicated why all alternatives required by the Planwould likely not be as effective for you as the requested drug; and/or would likely cause adverse reaction(s)or other harm to you. Therefore, an exception to the Plan's coverage criteria is not supported. Our PhysicianReviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are not met.Therefore, the Plan is not required to cover Humalog.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Cosentyx. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Cosentyx. The drug is requested to treat psoriasis vulgaris. The enrollee does not satisfy the Plan's coverage criteria. You have not sufficiently addressed the Plan's coverage criteria and/or have 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. Our Physician's opinion is that neither prior authorization nor prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is not required to cover Cosentyx.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Stelara. The Plan did not grant this request. We received this case to conduct an independent review.We asked a Physician Reviewer to determine whether the Plan was correct in denying the request for Stelara which is subject to prior approval. Our Physician Reviewer needed additional information from the prescriber to make this determination. The prescriber was asked to address whether the drugs offered by the Plan for the treatment of the enrollee's condition would: (1) not be as effective as the requested drug; and/or (2) have adverse effects. The requested information was not received. Based on a review of the available documentation, neither prior authorization criteria nor prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is not required to cover Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover and provide reimbursement for Tylenol Extra Strength 500 mg, Sennosides Docusate, Mag-AL Plus XS, Icy Hot Medicated Patch, Omeprazole DR 20 mg, Lidocaine 2% Solution, Diclofenac 1% Gel, Amlodipine Besylate 10 mg, Sulcralfate 1 gm, Losartan Potassium 100 mg and Atenolol 25 mg received October 24, and October 25, 2019 while a patient at the hospital. The Plan did not grant this request. We received this case to conduct an independent review.Tylenol Extra Strength 500 mg, Sennosides Docusate, Mag-AL Plus XS, Icy Hot Medicated Patch:Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drug's classification or determined from other available resources that the drug is a non-prescription or OTC drug. Therefore, Tylenol Extra Strength 500 mg, Sennosides Docusate, Mag-AL Plus XS and Icy Hot Medicated Patch received October 24, and October 25, 2019 while a patient at the hospital are not eligible for Part D coverage, and the Plan is not required to cover them under the Part D benefit. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefitOmeprazole DR 20 mg, Lidocaine 2% Solution, Diclofenac 1% Gel, Amlodipine Besylate 10 mg, Sulcralfate 1 gm, Losartan Potassium 100 mg and Atenolol 25 mg:We are dismissing the request for Omeprazole DR 20 mg, Lidocaine 2% Solution, Diclofenac 1% Gel, Amlodipine Besylate 10 mg, Sulcralfate 1 gm, Losartan Potassium 100 mg and Atenolol 25 mg. The Part D Plan provided documentation that the request for coverage or payment for Omeprazole DR 20 mg, Lidocaine 2% Solution, Diclofenac 1% Gel, Amlodipine Besylate 10 mg, Sulcralfate 1 gm, Losartan Potassium 100 mg and Atenolol 25 mg received October 24 and October 25, 2019 while a patient at the hospital was approved as requested. Since the Plan has agreed to provide coverage or payment, there is no need for a reconsideration review. Contact the Part D Plan to learn more about how and when coverage or payment will be provided for Omeprazole DR 20 mg, Lidocaine 2% Solution, Diclofenac 1% Gel, Amlodipine Besylate 10 mg, Sulcralfate 1 gm, Losartan Potassium 100 mg and Atenolol 25 mg received October 24 and October 25, 2019 while a patient at the hospital.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover or provide reimbursement for Meloxicam 15 mg, Atorvastatin 10 mg,Amlodipine 5 mg, Clonazepam 0.5 mg, Sodium Chloride, Donepezil 10 mg, Hydrochlorothiazide 12.5 mg,Losartan 50 mg, Eucerin Cream, Tamsulosin 0.4 mg, Gabapentin 300 mg, Omeprazole 20 mg, Vitamin D,Memantine 10 mg, Acetaminophen 325 mg, Allopurinol 100 mg, Oxybutynin 10 mg and L-Methyl allpurchased between January 26, 2020 and February 24, 2020 at the Pharmacy. The Plan did notgrant this request. We received this case to conduct an independent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If you pay thefull cost of a prescription drug out-of-pocket you can ask the Plan to pay you back. When submitting arequest for reimbursement, the Plan requires that you submit your receipt documenting the payment youhave made along with your reimbursement request. You submitted a request for reimbursement to the Planfor Meloxicam 15 mg, Atorvastatin 10 mg, Amlodipine 5 mg, Clonazepam 0.5 mg, Sodium Chloride,Donepezil 10 mg, Hydrochlorothiazide 12.5 mg, Losartan 50 mg, Eucerin Cream, Tamsulosin 0.4 mg,Gabapentin 300 mg, Omeprazole 20 mg, Vitamin D, Memantine 10 mg, Acetaminophen 325 mg,Allopurinol 100 mg, Oxybutynin 10 mg and L-Methyl all purchased between January 26, 2020 andFebruary 24, 2020 at the Pharmacy. The case record does not include proof of payment.Therefore, our decision is the Plan is not required to provide reimbursement for Meloxicam 15 mg,Atorvastatin 10 mg, Amlodipine 5 mg, Clonazepam 0.5 mg, Sodium Chloride, Donepezil 10 mg,Hydrochlorothiazide 12.5 mg, Losartan 50 mg, Eucerin Cream, Tamsulosin 0.4 mg, Gabapentin 300 mg,Omeprazole 20 mg, Vitamin D, Memantine 10 mg, Acetaminophen 325 mg, Allopurinol 100 mg,Oxybutynin 10 mg and L-Methyl all purchased between January 26, 2020 and February 24, 2020 atthe Pharmacy.Please note once you have paid your bill in full you can resubmit your request for review to your Part DPlan.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Bupropion HCL XL. The Plan did not grant thisrequest. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor a tiering exception for Bupropion HCL XL. The drug is requested to treat major depressive disorder.Bupropion HCL XL is a generic drug on Tier 3 of the Plan's formulary. The prescriber sent a letter statingthat the enrollee tried and failed or had adverse effects with Escitalopram. The prescriber does not statewhy all available lower tier alternatives on the Plan's formulary to treat the enrollee's condition (1) wouldnot be as effective for the enrollee as the requested drug and/or (2) would have adverse effects for theenrollee. Therefore, an exception to these criteria is not supported. Our Physician Reviewer's opinion is thattiering exception criteria are not met.Medicare rules require a Plan to grant an exception to its tiering structure whenever it determines that thehigher cost-sharing tiered drug for treatment of the enrollee's condition is medically necessary consistentwith the prescriber's statement. Our Physician Reviewer's opinion is that tiering exception criteria are notmet. Therefore, our decision is the Plan is not required to provide a tiering exception for Bupropion HCLXL.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Austedo . The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Austedo.The drug is requested to treat Chorea due to Huntington's disease. The enrollee does not satisfy the Plan'scoverage criteria. The prescriber has not sufficiently addressed the Plan's coverage criteria and/or has notindicated why all alternatives required by the Plan would likely not be as effective for the enrollee as therequested drug, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Our Physician'sopinion is that neither prior authorization nor prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. APlan must grant an exception to prior approval rules if it determines that the requested drug is medicallynecessary, consistent with the prescriber's statement. Based on the available documentation, our PhysicianReviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is notrequired to cover Austedo.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Combivent Respimat. The Plan did not grant thisrequest. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor a tiering exception for Combivent Respimat (Ipratropium/Albuterol) 20 mcg/100 mcg. The drug isrequested to treat the enrollee's condition. The drug is a brand drug on Tier 4 of the Plan's formulary. Thereare no available lower tier short-acting muscarinic antagonist (SAMA)//short-acting beta agonist (SABA)combination brand drugs on the Plan's formulary to treat the enrollee's condition. Therefore, the drug is noteligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are notmet.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of thesame type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in alower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug isbeing used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met becausethere are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition.Therefore, our decision is the Plan is not required to provide a tiering exception for Combivent Respimat.