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

At issue is Estradiol 1-milligram tablet prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee purchased the requested drug for an amount that is less than or equal to the required deductible and/or copayment amount. The plans 2021 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined the enrollees cost for the covered drug was calculated based on their cost share stage at the point of sale, and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 100-milligram capsule prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee purchased the requested drug from a preferred pharmacy for an amount that is less than or equal to the required deductible and/or copayment amount. The plans 2021 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined the enrollees cost for the covered drug was calculated based on their cost share stage at the point of sale, and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Progesterone 200-milligram capsule prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee purchased the requested drug for an amount that is less than or equal to the required deductible and/or copayment amount. The plans 2021 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined the enrollees cost for the covered drug was calculated based on their cost share stage at the point of sale, and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sertraline 50-milligram tablet prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee purchased the requested drug for an amount that is less than or equal to the required deductible and/or copayment amount. The plans 2021 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined the enrollees cost for the covered drug was calculated based on their cost share stage at the point of sale, and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Aer HF prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee purchased the requested drug for an amount that is less than or equal to the required deductible and/or copayment amount. The plans 2021 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. Based on the submitted claim information, we determined the enrollees cost share for the covered drug was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alendronate 70-milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee purchased the requested drug for an amount that is less than or equal to the required deductible and/or copayment amount. The plans 2021 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. Based on the submitted claim information, we determined the enrollees cost share for the covered drug was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anastrozole 1-milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee purchased the requested drug for an amount that is less than or equal to the required deductible and/or copayment amount. The plans 2021 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. Based on the submitted claim information, we determined the enrollees cost share for the covered drug was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Famotidine 20-milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee purchased the requested drug for an amount that is less than or equal to the required deductible and/or copayment amount. The plans 2021 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. Based on the submitted claim information, we determined the enrollees cost share for the covered drug was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lisinopril 5-milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee purchased the requested drug for an amount that is less than or equal to the required deductible and/or copayment amount. The plans 2021 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. Based on the submitted claim information, we determined the enrollees cost share for the covered drug was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mesalamine 0.375-gram 24 hour capsule prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee purchased the requested drug for an amount that is less than or equal to the required deductible and/or copayment amount. The plans 2021 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. Based on the submitted claim information, we determined the enrollees cost share for the covered drug was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60-milligram/milliliter solution prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee purchased the requested drug for an amount that is less than or equal to the required deductible and/or copayment amount. The plans 2021 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. Based on the submitted claim information, we determined the enrollees cost share for the covered drug was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tamoxifen 20-milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee purchased the requested drug for an amount that is less than or equal to the required deductible and/or copayment amount. The plans 2021 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. Based on the submitted claim information, we determined the enrollees cost share for the covered drug was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine Hydrochloride 6.25-milligram/5-milliliter syrup to treat chronic nausea related to gastroparesis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Movantik 25 milligram tablet to treat drug-induced constipation. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Ethosuximide 250-milligram capsules to treat epilepsy. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Ethosuximide is a generic drug on Tier 3 of the plans formulary.  The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception. A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Plavix 75-milligram tablet for thrombosis prophylaxis in Protein C deficiency. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. 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 documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Nurtec 75-milligram oral disintegrating tablet to treat chronic migraine without aura, intractable, without status migrainosus. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs/biologics are not eligible for a tiering exception.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Effexor 75-milligram capsule extended release to treat depression. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The requested drug is not on the plans formulary. 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 documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm. 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 Memantine Hydrochloride ER (extended release) 28-milligram capsule to treat multiple myeloma, neuropathy, and chronic pain. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benlysta 200-milligram/milliliter auto-injector to treat systemic lupus erythematosus. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ocetreotide Acetate 1000-micrograms/milliliter vial to treat hypoglycemia after gastrointestinal surgery, post-surgical malabsorption. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humulin R 500 unit/milliliter solution vial to treat type two diabetes mellitus. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The drug is given via an insulin pump in the home and is subject to Part B. This drug is not eligible for coverage under Part D drug benefits. However, this drug may be covered under Medicare Part B benefits.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Abiraterone Acetate 250 milligram tablet for the treatment of prostate cancer. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.  A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliqusi 5-milligram tablet to treat the enrollee's condition . The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including 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 diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Travoprost 0.004-percent eye drops to treat primary open-angle glaucoma. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.Travoprost is a generic drug on Tier 3 of the plans formulary. The prescriber has not addressed all drugs on the lower tiers of the plans formulary to treat the noted condition and provided patient specific clinical rationale as to why each lower-tiered drug would be less effective as the requested drug, is contraindicated, and/or or has been tried and failed.A physician reviewer determined that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trelegy Ellipta 100-62.5-blisters with device to treat chronic obstructive pulmonary disease with chronic bronchitis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Trelegy Ellipta 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 diagnosis. Therefore, this drug is not eligible for a tiering exception. A physician reviewer determined that the tiering exception criteria are not met.