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

At issue is Forteo solution 20 micrograms/2.4 milliliter injection pen prescribed as directed for osteoporosis. The Part D plan denied the 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 records submitted at the reconsideration level. The medical records show you were prescribed Forteo injection pen for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has been met. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Forteo injection pen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tremfya 100 milligram/milliliter subcutaneous auto-injector to treat plaque psoriasis. The Part D plan denied the request. The requested drug is not on the plans formulary. We received a 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.The prescriber has provided patient specific clinical rationale and medical records. However, the documentation does not sufficiently address why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ascomp w/Codeine 50-325-40-30 milligram capsules prescribed as needed for chronic migraine without aura, not intractable, without status migrainosus. The Part D plan denied your 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. Your medical records show your doctor prescribed Ascomp w/Codeine as needed to treat your chronic migraine without aura, not intractable, without status migrainosus. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.   A physician reviewed your appeal and determined that the plan is not required to cover the Ascomp w/Codeine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% Ointment prescribed to treat an abrasion, unspecified lower leg, initial encounter. 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.We requested additional information from the prescriber but there was no response. Medicare approved compendia does not support the use of the drug for your conditionA physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% Ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick Auto-injector. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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

You requested Hetlioz 20 milligram capsules prescribed for the management of circadian rhythm sleep disorder free run type, non-24-hour sleep-wake disorder. 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. The documentation does not satisfy the plans coverage criteria. The prescriber has addressed the prior authorization criteria; however, the responses do not satisfy all of the plans requirements for coverage of this medication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 250 milligram tablets prescribed for attention deficit hyperactivity disorder. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. The submitted documentation indicates your doctor originally prescribed Armodafinil for attention deficit hyperactivity disorder. The Medicare approved compendia do not support the use of this drug for your condition. Your doctor submitted a statement to indicate the prescribed diagnosis should be obstructive sleep apnea; however, no medical records were submitted to corroborate a change in diagnosis. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Zaleplon 5 milligram capsule to treat insomnia. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The physician submitted a supporting statement. The prescriber statement indicates that the enrollee has tried Trazodone. As such, the documentation supports an approved diagnosis and a prior alternative. Therefore, the documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Zaleplon.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Enbrel 500 milligram/milliliter pen injection to treat plaque 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 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 plan requires for continuation of Enbrel that the enrollee have an intolerance to one non-biologic immunomodulator. The documentation includes clinical notes which satisfied the plan's coverage criteria. The medical records document that the enrollee has tried and failed or had an adverse effect with Soriatane and Methotrexate.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Shingrix vaccine prescribed for shingles vaccination. The Part D plan denied your request.We received a case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows you received the Shingrix vaccine from your physician on September 26, 2018. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plans formulary shows the drug is covered as a Tier 3 drug. The documentation submitted includes a physicians statement indicating you paid for the vaccine and its administration fee in full. We determined that the plan is required to reimburse you for their share of the cost for the Shingrix vaccine and administration fee.
Appeal type: Prescription Drug
Decision: Favorable

You requested Lidocaine 5% patch prescribed for shingles. The Part D plan denied your request.We received a case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased the Lidocaine patch from a network pharmacy on January 5, 2021. The plan provided documentation showing the drug was payable. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The documentation submitted includes a receipt showing you paid for the Lidocaine patch in full. We determined that the plan is required to reimburse you for their share of the cost for the Lidocaine patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyzulta solution prescribed for intraocular pressure. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.Your physician submitted a supporting statement. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Vyzulta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Premarin 0.9 milligram tablets prescribed for menopausal symptoms. 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. Premarin is not included in your plans formulary. Your doctor has not sufficiently addressed why all of the medications that are included in your plans formulary to treat your condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans 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 Tadalafil 5 milligram tablets prescribed for erectile dysfunction related to prostatectomy. The Part D plan denied your request because drugs being used for the treatment of erectile dysfunction are excluded from coverage by Medicare Part D. 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 determined that the plan is not required to cover Tadalafil. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Hetlioz 20 milligram capsules prescribed for the management of circadian rhythm sleep disorder free run type, non-24-hour sleep-wake 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 your case file carefully. We reviewed all documentation submitted. The documentation does not satisfy the plans coverage criteria. The prescriber has addressed the prior authorization criteria; however, the responses do not satisfy all of the plans requirements for coverage of this medication. 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 a tiering exception request for Restasis 0.05% eye drops prescribed as directed for dry eye syndrome. The Part D plan denied the 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.Restasis 0.05% 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. A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception for Restasis eye drops.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil citrate 20 milligram tablet prescribed as directed for prostate cancer. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.No medical records were provided by the prescriber. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the Sildenafil citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Breo Ellipta Inhalation Powder 100 microgram-25 microgram/actuation to treat asthma. 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.Breo Ellipta Inhalation Powder 100 microgram-25 microgram/actuation is a brand drug on Tier 2 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 a tiering exception request for Lantus 100 units per milliliter to treat the enrollees condition. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read the documentation submitted. This includes any information submitted at the reconsideration level.Lantus 100 units per milliliter 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 Intrarosa 6.5 milligram vaginal inserts to treat the diagnosis of uterine prolapse and vaginal atrophy. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnoses 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 your conditions. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Intrarosa 6.5 milligram vaginal inserts.
Appeal type: Prescription Drug
Decision: Favorable

You requested Shingrix vaccine prescribed for shingles vaccination. The Part D plan denied your request.We received a case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows you received the Shingrix vaccine from your physician on June 18, 2020. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plans formulary shows the drug is covered as a Tier 3 drug. The documentation submitted includes a money order indicating you paid for the vaccine and its administration fee in full. We determined that the plan is required to reimburse you for their share of the cost for the Shingrix vaccine and administration fee.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eucrisa 2 % topical ointment prescribed twice daily to treat atopic dermatitis. The Part D plan denied the 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 records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Eucrisa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xiidra 5% solution prescribed to instill 2 drops into both eyes every 12 hours to treat the diagnosis of dry eye syndrome. 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.Xiidra is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Xiidra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Armour Thyroid 120 milligram tablets prescribed for hypothyroidism. 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 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.This drug is not on the plans formulary. In addition, it is not Food and Drug Administration approved. Per Medicare rules, non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage and therefore not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tymlos Solution Pen-injector to treat osteoporosis. 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 a prescriber statement and medical records to show why the enrollee needs this medication. We received the documentation and included it in our review.The documentation available does satisfy the plans coverage criteria. The prescriber has sufficiently addressed the plans coverage criteria and the coverage criteria are satisfied by the provided medical records and prescriber statement.A physician reviewed your appeal and determined that the plan is required to cover Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Serevent 50 micrograms prescribed twice daily for asthma. 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 also researched Medicare systems and reviewed the enrollment data available.The plan requires an intolerance or contraindication to conventional therapy before they will cover the requested drug. The prescriber has not sufficiently indicated why all alternatives required by the plan would likely cause harm or not be as effective for the enrollee as the requested drug. The documentation provided 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 Serevent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligram extended-release oral tablet prescribed daily for urge incontinence. The Part D Plan denied your request for a tiering 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. Myrbetriq 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

You requested coverage for Testosterone 10 milligram/0.5 gram per actuation gel pump for the treatment of male hypogaonadism. 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. Testosterone 10 milligram/0.5 gram per actuation gel pump is not included in the plans formulary. The prescriber has not sufficiently addressed why all alternative medications that are included in the plans formulary to treat the noted condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.