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

At issue is Metformin 1000 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined the copay was calculated correctly, based on the pharmacy price of the drug and the enrollees cost share stage. Therefore, no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pantoprazole 40 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined the copay was calculated correctly, based on the pharmacy price of the drug and the enrollees cost share stage. Therefore, no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rosuvastatin 5 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined the copay was calculated correctly, based on the pharmacy price of the drug and the enrollees cost share stage. Therefore, no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Entresto 24-26-milligram tablet to treat nonischemic cardiomyopathy and congestive heart failure. 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.Entresto 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 the request and determined that the drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Methazolamide 50 milligram tablets to treat the diagnosis of Menieres disease. The Part D plan denied the appeal request.We received the case to perform 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 documentation shows your doctor prescribed Methazolamide 50 milligram tablets to treat Menieres disease. However, the Medicare approved compendia do not support the use of this drug for the enrollees 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 Methazolamide 50 milligram tablets. The physician reviewer also determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Praluent 75 milligram/milliliter pen prescribed for coronary artery disease and hyperlipidemia. 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 plan provided documentation showing the requested drug was approved as a formulary exception and therefore, ineligible for a tier exception (co-pay reduction). There was no proof of payment by the enrollee for the requested drug to consider reimbursement criteria as met. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% Patch to treat chronic right shoulder 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 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 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 condition. Therefore, the requested drug 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 a tiering exception request for Dofetilide 500 microgram capsules. 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 medical records indicate that Dofetilide has been prescribed for the treatment of unspecified heart arrhythmia. However, the approved Medicare compendia do not contain any citations to support the use of Dofetilide for the treatment of the noted condition. Although the drug is being used for a non-medically accepted indication, the plan has approved coverage of the drug, which is on Tier 4 of the plans formulary. However, a tiering exception will not be granted by the plan for a drug that is being used for an indication that is not cited in the approved Medicare compendia. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier. The drug will continue to be covered at the Tier 4 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ethacrynic Acid 25 milligram tablet prescribed for edema. 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. Ethacrynic Acid 25 milligram tablet is prescribed for edema, unspecified in an enrollee with chronic kidney disease, stage four. This 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. We requested additional information from the prescriber but did not receive a response. In this case, the prescriber does not indicate why all the other alternative on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Ethacrynic Acid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10-milligram tablets prescribed for insomnia. The Part D plan denied the request. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. This drug is considered a high-risk medication in older enrollees. 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed, with support of medical records, the issues regarding this high-risk medication, and why alternative safer medications, in the plan's formulary, could not be used. 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 Corlanor 5-milligram tablets prescribed for postural orthostatic tachycardia syndrome. 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 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 documentation submitted shows the prescriber ordered Corlanor to treat the enrollees condition of postural orthostatic tachycardia syndrome. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin Hydrochloride 1,000 milligram tablets prescribed to treat an unknown diagnosis for the date of service May 22, 2021.We received the case to perform 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 are dismissing this case because your Part D plan showed that the request for coverage or payment for Metformin Hydrochloride 1,000 milligram tablets for date of service May 22, 2021, was approved. Since the plan has agreed to provide coverage or payment, there is no need for a reconsideration review.Contact the Part D plan directly to learn more about how coverage or payment will be provided for Metformin Hydrochloride 1,000 milligram tablets for date of service May 22, 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 125 microgram tablets prescribed to treat an unknown diagnosis with the date of service May 22, 2021.We received the case to perform 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.According to the plans Evidence of Coverage, limits and restrictions are placed on drugs that are refilled too soon. Therefore, the claim for the date of service May 22, 2021, was rejected at point of sale for refill too soon, and the amount charged to the enrollee was an out-of-pocket expense. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Icosapent Ethyl 1 gram capsule to treat hyperglyceridemia. 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.The prescriber has provided patient specific clinical rationale and medical records. However, the documentation does not address why all alternatives required by the plan would likely not be as effective as; 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: Favorable

At issue is a prior authorization request for Droxidopa 100-milligram capsules prescribed for neurogenic orthostatic hypotension. The Part D plan denied coverage.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 records submitted at the reconsideration level. We requested additional documentation from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee met the plans prior authorization coverage criteria. We received additional documentation and included it in the review.The enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement to support the enrollee was prescribed the drug at issue for the noted condition. The submitted documentation supports the enrollee has a persistent, consistent decrease in systolic blood pressure of at least 20 millimeters of Mercury within three minutes of standing, and the enrollee has pure autonomic failure. The plans prior authorization coverage criteria has been met.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 10-milligram/20-milligram/30-milligram starter pack prescribed for hidradenitis suppurativa. 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 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 documentation submitted shows the prescriber ordered Otezla to treat the enrollees condition of hidradenitis suppurativa. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lotemax 0.5% Solution Eye Drops to treat keratoconjunctivitis sicca. The Part D plan denied the request. The requested drug is not on the plans formulary. 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.We asked your prescriber to send us a prescriber statement, a medically accepted indication (diagnosis), answers to off formulary exception coverage criteria, and medical records. However, we did not receive the documentation.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. 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 20 milligram tablets prescribed as directed for schizophrenia. 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 records submitted at the reconsideration level. 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 did not receive the documentation requested.Your medical records show your doctor prescribed Latuda to treat your schizophrenia. Your plan has prior authorization requirements for this drug that must be met before they will cover 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 Latuda.
Appeal type: Prescription Drug
Decision: Favorable

You asked for reimbursement for Atrovent HFA 17 microgram/actuation aerosol inhaler solution prescribed for acute exacerbation of chronic obstructive pulmonary disease. 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 enrollee was seen in the emergency department for shortness of breath. An Atrovent inhaler was prescribed to treat an acute exacerbation of chronic obstructive pulmonary disease which was purchased on January 12, 2021, for $962.99. The enrollee has submitted the receipt and the order for the drug was a quantity of 1 with days supply stating as one time.'  The drug is on the plans formulary with no prior authorization requirements noted and there is no quantity ordered over the plans limit for that drug. The documentation supports that reimbursement criteria has been met.  A physician reviewed your appeal and determined that the plan is required to reimburse payment for Atrovent HFA inhaler solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 2.5 milligram oral tablets prescribed to treat the enrollees condition. The Part D plan denied the appeal request for a tiering exception.We received the case to perform 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.Eliquis 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Privigen solution 20 gram/200 milliliter to treat hypogammaglobinemia following chemotherapy. 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 Privigen was prescribed to treat hypogammaglobinemia following chemotherapy. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Privigen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ajovy 225-milligrams/1.5-milliliter Subcutaneous Auto-Injector to treat migraine with aura intractable without status migrainosus. The Part D plan denied the request. The requested drug is not on the plans formulary. 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.We asked your prescriber to send us a prescriber statement, answers to off-formulary exception coverage criteria, and medical records. We received medical records similar to the records submitted at redetermination.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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyepti 100 milligrams/milliliter vial prescribed as directed for chronic migraine without aura, not intractable, without status migrainosus. 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 Vyepti.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 5 milligram tablet prescribed daily for skeletal muscle spasm associated with chronic bilateral shoulder 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 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 documentation shows the prescriber ordered Cyclobenzaprine Hydrochloride to treat the enrollees skeletal muscle spasm associated with chronic bilateral shoulder pain beginning in 2014. The Medicare approved compendia do not support the use of this drug for this chronic diagnosis. A physician reviewed the appeal and determined that the plan is not required to cover Cyclobenzaprine Hydrochloride.