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

At issue is Lumigan 0.01 percent eye solution prescribed as directed for glaucoma. The Part D plan denied your request for a tiering 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. Lumigan 0.01 percent eye solution 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 to treat your condition. 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 Lumigan 0.01 percent eye solution because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium-albuterol 0.5-3 milligrams per 3 milliliters solution for nebulization to treat chronic obstructive pulmonary disease. The Part D Plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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 systems and reviewed the enrollment data available.Based on the information provided, we determined the drug would be eligible for coverage under Part B.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Idhifa 100 milligrams prescribed for metastatic cholangiocarcinoma. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. 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. Your medical records show your doctor prescribed Idhifa to treat your metastatic cholangiocarcinoma. However, the Medicare approved compendia does not support the use of this drug for your condition. Idhifa has only been approved to treat acute myeloid leukemia.A physician reviewed your appeal and determined that the plan is not required to cover Idhifa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brilinta, 60 milligram tablets prescribed for anticoagulation with a history of peripheral artery disease and deep venous thrombosis. The Part D Plan denied your request for a tiering exception because there were no other brand drugs appropriate to treat your condition on a lower cost-sharing tier. 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. Brilinta is a brand name drug on Tier 3 of the plans formulary. There are no brand name drugs of the same type on the lower cost sharing tiers. If there are no brand name drugs of the same type on a lower tier, the drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover the Brilinta at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mesalamine, 1000 milligram suppositories for the treatment of radiation proctitis and hemorrhoids. The Part D plan denied your request because these conditions are not medically accepted indications for the use of this medication. 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.  A physician reviewed your appeal and determined that the plan is not required to cover the Mesalamine because radiation proctitis and hemorrhoids are not medically accepted indications to use this drug.The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted conditions. Therefore the requested drug is not being prescribed foe medically accepted indications as defined by Medicare law.  As such, the requested drug does not meet the definition of a Medicare Part D drug and is therefore not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is sildenafil 20 milligrams to treat erectile dysfunction. The Part D plan denied the request stating that the provided diagnosis is a non-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 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 the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D. The plan is not required to cover sildenafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zonisamide 100 milligrams to treat peripheral neuropathy in a patient with diabetes mellitus. The Part D Plan denied the request stating that the provided diagnosis is a non-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. We received medical records that were not in the plan's case file. 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 the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Repatha Sureclick Auto Injector, 140 milligrams/milliliter to treat hyperlipidemia. The Part D Plan denied the request because your prescriber did not provide the detailed information that is required in order to approve the request for a formulary exception. 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 your doctor prescribed Repatha Sureclick Auto Injector to treat your hyperlipidemia. The Medicare compendia approve the use of Repatha Sureclick Auto Injector for your condition. Your doctor 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: Unfavorable

At issue is a tiering exception request for Eliquis 5 mg to treat atrial fibrillation.   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.Eliquis 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

You requested the Tetanus and Diphtheria Toxoids vaccine. The Part D plan did not make a coverage determination. We received an auto-forwarded reconsideration request from the enrollee.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 records show you have a receipt for the Tetanus and Diphtheria Toxoids vaccine and are requesting reimbursement. According to your Evidence of Coverage for your health plan, immunizations are covered by Medicare Part B if the criteria has been met.A physician reviewed your appeal and determined that the TDAP is eligible for coverage under Medicare Part B. The documentation submitted did not support the vaccine was administered for a routine reason. Therefore, the drug cannot be considered for payment under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tetrabenazine 25 milligrams prescribed daily for chorea. The Part D plan denied your request for a tier change request because Tetrabenazine is in the specialty tier of your list of covered drugs. The drug was approved for coverage on January 22, 2021, at Tier 5. 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 Tetrabenazine is being prescribed for chorea. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Tetrabenazine is a generic Tier 5 drug. Your plan does not allow you to receive drugs in this tier at a lower cost share.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 50 milligrams prescribed daily. The Part D plan denied your request for a tiering exception. We received an expedited 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. Myrbetriq ER 50 milligrams 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 cover Myrbetriq ER 50 milligrams because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Saphris 10 milligram sublingual tablets.   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.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

You requested Nyamyc powder prescribed as directed for candida intertrigo. The Part D plan denied your request because the quantity limit requested is higher than what the plan allows. 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. Your medical records show your doctor prescribed Nyamyc powder to treat your candida intertrigo. The amount you were prescribed exceeds the plans number of doses that may be dispensed. There was no supporting evidence submitted to show why you require this amount. Therefore, an exception to the amount of drug requested cannot be made as the limit criteria was not met. A physician reviewed your appeal and determined that the plan is not required to cover the Nyamyc, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin HCL Extended Release 20 milligram tablet to treat Chronic pain due to trauma. 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: Unfavorable

You requested Zolpidem Tartrate Extended Release, 6.25 milligrams prescribed one, 30 minutes before bedtime for chronic insomnia. The plan denied the request because the drug is non-formulary (not on Humana's list of preferred drugs). If you have not tried the preferred drugs, including trazodone tablet, Belsomra tablet, please talk to your health care provider about prescribing one of these for you. 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.Your doctor prescribed Zolpidem Tartrate Extended Release for chronic insomnia. 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. Although the enrollee has tried multiple drugs, there are additional drugs on the formulary that have not been tried. Office notes indicate Belsomra was not attempted due to cost issues alone. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewer's opinion is that the formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Welchol 625 milligram tablet prescribed for hypercholesterolemia. The Part D plan denied coverage because there was insufficient documentation to support that the prior authorization criteria were met. We received an expedited 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 records submitted at the reconsideration level. The physician submitted a supporting statement. The prescriber statement indicates the physician had prescribed Welchol because the enrollee is unable to tolerate statin therapy and has a diagnosis of fibromyalgia.However, the plan requires documentation of the enrollees response to treatment on cholestyramine before they will cover the requested drug. The documentation available for review does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Welchol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligrams to treat psoriasis. 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 enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan would likely cause harm or not be as effective for the enrollee as the requested drug. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levetiracetam extended release 500 milligram tablets prescribed for the diagnosis of epilepsy. The Part D plan denied your request because the documentation did not support the lower tiering exception criteria. We received are request to reconsider the appeal.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 Levetiracetam extended release 500 milligram tablets is being prescribed to treat the enrollees condition. Levetiracetam extended release 500 milligram tablet is a generic name drug on Tier 4 of the plan's formulary. Medicare approved compendium support the use of the requested drug for your condition.The prescriber statement indicates that the enrollee was taking Oxcarbaepine and Levetiracetam at bedtime for epilepsy. The prescriber statement also indicates that Gabapentin was tried with insufficient effectiveness; Phenytoin, Primidone, Topiramate, Depakote, and Zonisamide were tried with enrollee exhibiting adverse effects; and Lamotrigine was tried and found to be problematic when added to Oxcarbazepine. However, the plans formulary includes other generic drugs that could be used to treat the enrollees condition. The medical records do not show all alternative drugs on the plan formulary have been tried or why enrollee cannot take them.A physician reviewed your appeal and determined that the plan is not required to cover a tier exception for Levetiracetam extended release 500 milligram tablets under your Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligrams per 2 milliliters syringe for treatment of chronic rhinosinusitis with nasal polyposis. The Part D plan denied the request. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted including the case file from the plan and any records submitted at the reconsideration level.The Part D plan denied the drug because the prior authorization criteria were not met.  The prescriber indicated 'no' on the question about continuation of intranasal corticosteroids, which is one of the required coverage criteria for Dupixent.A physician reviewed your appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prevacid Delayed Release, 30 milligrams prescribed one capsule daily for gastroesophageal reflux disease. You asked the Part D plan to provide a cost-sharing tiering exception. The plan denied the appeal because this drug is not listed on your formulary plan (non-formulary). A tiering exception (co-pay reduction) for a non-formulary drug cannot be approved. 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. Your medical records show Prevacid Delayed Release is being prescribed for gastroesophageal reflux disease. This drug is not listed on your plans formulary. Additionally, your doctor did not include medical records verifying that you had tried alternative generic drugs and with results within the last 180 days for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Prevacid Delayed Release because the criteria for coverage for a formulary tiering exception has not been met per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Smoflipid 20% fat emulsion for total parenteral nutrtion. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D benefit. We received an expedited reconsideration 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 also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug would be eligible for coverage under Part B.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Megestrol Suspension 625 milligrams per 5 milliliers prescribed for unexplained weight loss and poor appetite. The Part D plan denied your request because the drug was prescribed for a non-medically accepted indication. We received an expedited 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.Your medical records document that your doctor prescribed Megestrol for unexplained weight loss and poor appetite following a kidney transplant. 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 Megestrol.