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

At issue is Nucynta ER 50 milligrams tablet prescribed to treat chronic pain. 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 prescriber has not provided patient specific clinical rationale, supported by medical records, as to 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.A physician reviewed your appeal and determined that the plan is not required to cover Nucynta ER 50 milligrams tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pilocarpine HCL 7.5 milligram tablets to treat Sjogren's syndrome-xerostomia. 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.Pilocarpine HCL is a generic drug on Tier 4 of the plans formulary. There are no generic 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Polyhexmethylene Biguanide 0.02% ophthalmic solution to treat your condition. 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 QIC notes this drug is a compounded drug (Polyhexmethylene Biguanide 20% liquid and injectable sterile water. Therefore, we reviewed each ingredient individually. We determined that the plan is not required to cover or reimburse Polyhexmethylene Biguanide 0.02% ophthalmic solution. The Polyhexmethylene Biguanide 20% liquid ingredient is not FDA approved as being safe and effective for the enrollees condition and the injectable sterile water is excluded from drug coverage under the Medicare Part D benefit. Your plan does not offer supplemental (additional) coverage for the requested drug. Therefore, the plan is not required to cover or provide reimbursement for the above-mentioned ingredients included in the Polyhexmethylene Biguanide 0.02% ophthalmic solution compound. If you purchased drugs that are excluded, you must pay for them yourself.A physician reviewed your appeal and determined that the plan is not required to cover or reimburse the above-mentioned ingredients for Polyhexmethylene Biguanide 0.02% ophthalmic solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Promethazine HCL 25 milligram tablets prescribed to treat nausea. 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 shows your doctor prescribed Promethazine HCL 25 milligram tablets to treat nausea secondary to diabetes mellitus with pancreatic disease. 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 Promethazine HCL 25 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trospium chloride ER 60 milligram capsules prescribed to treat stress incontinence. 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 prescriber has not provided patient specific clinical rationale, supported by medical records, as to 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. A physician reviewed your appeal and determined that the plan is not required to cover Trospium chloride ER 60 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lynparza 100 milligram tablets prescribed as directed to treat non-small cell lung cancer. 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 shows the enrollee has a history of breast cancer and was newly diagnosed with metastatic lung cancer. The ataxia-telangiesctasia mutated gene was identified by Guardant 360 testing. Therefore, the doctor prescribed Lynparza to treat the enrollees metastatic lung cancer. The provider submitted medical literature for review. 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. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  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.A physician reviewed your appeal and determined that the plan is not required to cover Lynparza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyzulta 0.024% solution one drop nightly both eyes prescribed for chronic angle-closure glaucoma, right eye, severe stage and chronic angle-closure glaucoma, left eye, mild stage. 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 Vyzulta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Patch 5% prescribed for rheumatoid arthritis. 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. Your physician states that the Lidocaine Patch is for neuropathy in an enrollee with diabetes and the wrong diagnosis had been submitted in the first appeal. No medical records were provided by the prescriber to support this diagnosis. 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 Lidocaine Patch 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a quantity limit exception for Hydrocodone Ibuprofen 7.5-200 milligram tablets. 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.The submitted documentation does not contain a supporting statement or medical records to corroborate the prescribed diagnosis. A request for additional information was sent to your doctor; however, no documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, a quantity limit exception cannot be allowed. Opioid medications require clear and thorough documentation to support medical necessity, this was not provided.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amitriptyline Hydrochloride 50 milligram tablet prescribed for an unknown diagnosis. 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 the plan reprocessed a claim for the Amitriptyline Hydrochloride and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clonazepam 1 milligram tablet prescribed for an unknown diagnosis. 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 the plan reprocessed claims for the Clonazepam and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clonidine Hydrochloride 0.1 milligram tablet prescribed for an unknown diagnosis. 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 the plan reprocessed a claim for the Clonidine Hydrochloride and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 4 milligram tablets. The Part D plan denied your request stating that the drug falls within an excluded class of drugs.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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We requested additional information from your prescriber but did not receive a response. There was no documentation supporting a diagnosis and why the drug was medically necessary. The documentation was insufficient to determine if the drug is medically indicated for your condition. The enrollee requested reimbursement for this drug but the request cannot be allowed because the coverage requirements were not met.  A physician reviewed your appeal and determined that the plan is not required to cover Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Escitaloprak 20 milligram tablets prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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 record shows you filled a prescription for Escitaloprak at a network pharmacy. Medicare records show that you do have Medicare Part D coverage with the Limited Income NET (LINET) program. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required coinsurance, and the difference between what the plan normally pays for the drug and what the pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that you paid for the drug was not provided. Therefore, we determined that the plan is not required to reimburse you without the required documentation. Please submit proof of payment to your plan for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pregabalin 100 milligram capsules prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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 record shows you filled a prescription for Pregabalin at a network pharmacy. Medicare records show that you do have Medicare Part D coverage with the Limited Income NET (LINET) program. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required coinsurance, and the difference between what the plan normally pays for the drug and what the pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that you paid for the drug was not provided. Therefore, we determined that the plan is not required to reimburse you without the required documentation. Please submit proof of payment to your plan for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rosuvastatin Calcium 20 milligram tablets. 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.Rosuvastatin Calcium is a generic drug on Tier 3 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

You requested Amantadine Hydrochloride 100 milligram tablet prescribed for your condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The record shows the Good RX discount was applied to the purchase because the insurance information was not up-to-date or not available. When your benefit card was used, you acknowledged and agreed that Good RX will be treated as the primary payor with respect to the medications that you have selected to purchase through the Good RX discount program. Therefore, the plan is not required to cover or provide reimbursement for Amantadine Hydrochloride.To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance without applying the Good RX discount.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Carbidopa-Levodopa 25-100 milligram tablet prescribed for your condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The record shows the Inside RX discount was applied to the purchase because the insurance information was not up-to-date or not available. When your benefit card was used, you acknowledged and agreed that Inside RX will be treated as the primary payor with respect to the medications that you have selected to purchase through the Inside RX discount program. Therefore, the plan is not required to cover or provide reimbursement for Carbidopa-Levodopa.To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance without applying the Inside RX discount.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rasagiline Mesylate 1 milligram tablet prescribed for your condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The record shows the Good RX discount was applied to the purchase because the insurance information was not up-to-date or not available. When your benefit card was used, you acknowledged and agreed that Good RX will be treated as the primary payor with respect to the medications that you have selected to purchase through the Good RX discount program. Therefore, the plan is not required to cover or provide reimbursement for Rasagiline Mesylate.To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance without applying the Good RX discount.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed to treat trigeminal neuralgia. 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 shows your doctor prescribed Lidocaine 5% patch to treat trigeminal neuralgia. 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% patch.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Sodium Fluoride chews prescribed daily for dental caries prophylaxis. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The medical records show the physician prescribed Sodium Fluoride for dental caries prophylaxis. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of the requested drug for your condition. 'Sodium Fluoride is effective in reducing the number of decayed, missing, or filled surface of teeth.'The records show that there are no other drugs that treat your condition in the plan's formulary.A physician reviewed your appeal and determined that an exception can be granted to cover the drug that is not on your plans formulary. Therefore, the plan is required to cover Sodium Fluoride chews.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Tretinoin 0.05% cream prescribed for acne. 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. Tretinoin is a generic drug on Tier 4 of the plans formulary. The prescriber has not addressed why all of the generic drugs of the same type on the lower tiers of the plans formulary to treat your condition have been tried and failed, or are contraindicated. A physician reviewed the appeal and determined that the plan is not required to cover the Tretinoin cream at a lower cost tier.
Appeal type: Prescription Drug
Decision: Favorable

At issue is prescribed Repatha Sureclick 140 milligram per milliliter 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. We also researched Medicare systems and reviewed the enrollment data available.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 received the documentation and included it in our review.Your medical records show your doctor prescribed Repatha to treat coronary artery disease and statin myopathy with a low-density lipoprotein level of 81. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. 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 Repatha. The prescriber statement and medical records show that statin therapy was discontinued and is contraindicated due to statin intolerance and due to the enrollee having a diagnosis of Lambert Eaton syndrome. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.