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

You requested reimbursement for Ursodiol 300 milligram capsules prescribed for unknown diagnosis.We received the 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 Ursodiol from a network pharmacy on March 6, 2020, for a copay of $227.72. Due to a shortage, the pharmacy was only able to partially fill your prescription. You were then able to pick up the remaining capsules on May 26, 2020, at no additional charge. The plan issued a letter requesting a recovery amount of $382.06 because they received updated information and the claims reprocessed. The plans formulary shows Ursodiol is a tier 4 drug. According to your plan's Evidence of Coverage, your cost share for a tier 4 drug purchased at a standard in-network pharmacy for a 90 day supply is 50%. The documentation submitted includes a pharmacy invoice indicating the total approved cost of the Ursodiol is $837 and your cost share is 50% of that cost, or $418.75. Therefore, we determined that the plan was incorrect in their calculation and the amount you owe is $191.03, in addition to the $227.72 already paid for the Ursodiol purchased on March 6, 2020. No additional charge should be applied for the May 26, 2020, date of service since this was the remaining quantity from the March 6, 2020, fill.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue coverage for Xtampza ER 27 milligram capsules prescribed for chronic pain syndrome. The Part D plan denied the request for coverage.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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed once a day for circadian rhythm sleep disorder, free running style. 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 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. The prescriber did not respond to a request for addition information. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation was not provided to 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 Hetlioz as the prior authorization requirements were not met. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20-milligram capsule to treat circadian rhythm sleep disorder, free running type. The 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.To support this diagnosis, the prescriber provided no medical records. 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 requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram oral capsule for circadian rhythm sleep disorder free run type. 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 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 Hetlioz. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lynparza 150 milligram tablets prescribed to treat metastatic adenoid cystic carcinoma. 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 doctor prescribed Lynparza to treat metastatic adenoid cystic carcinoma, extensive disease that is triple negative. Molecular testing was performed and shows BRCA 2 mutation. The National Comprehensive Cancer Network guidelines show Lynparza is recommended for adenoid cystic carcinoma as singe agent for metastatic HER2 negative, BRCA 1 or 2 positive disease that is hormone negative. However, the molecular testing that was performed is not a Food and Drug Administration approved test. The documentation submitted does not include the results of a Food and Drug Administration approved test confirming the presence of the required mutations. 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 Lynparza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Prolensa 0.07% ophthalmic drops. The Part D plan denied the request for coverage because the medication was not included in the plans formulary and the prescriber did not address why the formulary alternatives would not work just as well.  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 at reconsideration indicates that Prolensa ophthalmic drops have been prescribed to treat persistent iritis due to multiple ocular conditions including chronic uveitis, history of steroid responsive ocular hypertension, and a history of retinal detachment with silicone oil, status post removal with implantation of an intraocular lens following cataract surgery. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Megestrol Acetate 40 milligram tablets prescribed for weight loss post Covid-19 infection.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pentasa ER 500 milligram capsules prescribed for Crohns disease. The Part D plan did not make a decision.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 information regarding the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. 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. In this case, the medical records do not support why other drugs on the plans formulary would not work. A physician reviewed your appeal and determined that the plan is not required to cover Pentasa ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Butalbital-Acetaminophen 50-325 milligram tablets prescribed daily for chronic migraines. 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 information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.At reconsideration a diagnosis of tension headache was given. 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.A physician reviewed your appeal and determined that the plan is not required to cover Butalbital-Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Repatha Sureclick 140 milligrams/milliliter injection pen prescribed as directed for atherosclerotic heart disease of native coronary artery without angina pectoris, Non-ST elevation (NSTEMI) myocardial infarction, and mixed hyperlipidemia. The Part D plan denied your request because the documentation did not support an off-formulary 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. We also researched Medicare systems and reviewed the enrollment data available. 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 Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ursodiol 500 milligram tablet prescribed for primary biliary cholangitis and liver cirrhosis. 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. Ursodiol is a generic drug on Tier 3 of the plans formulary. There are no generic 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 a tiering exception for Botox 100 unit vial for spasticity, upper or lower limb. The Part D plan denied your request for a tiering exception because Botox is a biologic Tier 4 drug and the lower cost-sharing tiers do not contain any alternative drugs for your condition. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan shows Botox is a biologic Tier 4 drug. There are no biologic drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brukinsa 80 milligram capsule prescribed for mantle cell lymphoma. 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.At initial coverage determination and redetermination, prescriber had indicated planned use in addition to Venetoclax. Brukinsa must be used as monotherapy, this request was denied. The current prescriber statement indicates Brukinsa will be used as monotherapy. However, the plans prior authorization criteria also state, as an exclusion criterium - The member has experienced disease progression while on or following a BTK inhibitor (e.g. ibrutinib, acalabrutinib, zanabrutinib). This enrollee has received ibrutinib on 2 occasions - in 2013 and 2017, and has had subsequent disease progression in both cases. 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 Brukinsa. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Reyvow 100-milligram tablets to treat migraine with or without aura. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kevzara 200-milligrams/1.4-milliliters injection to treat rheumatoid arthritis multiple site. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligrams/milliliter syringe prescribed as directed for 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Prolia to treat your osteoporosis. 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 Prolia because the plans prior authorization requirements were not met. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac epolamine1.3% Patch to treat an unknown diagnosis.  The Part D plan denied the request stating that criteria for coverage were not met.  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.At reconsideration relevant medical records were requested.  No medical records were provided by the prescriber to support a 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide Suspension 0.5-milligrams/2-milliliters. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.  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 Lidocaine-Prilocaine 2.5%-2.5% cream prescribed for treatment of pain associated with puncture for hemodialysis. 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. We also researched Medicare systems and reviewed the enrollment data available.The record shows you have a diagnosis of end stage renal disease on hemodialysis and the Lidocaine-Prilocaine cream was prescribed for numbing prior to accessing your hemodialysis fistula. However, this drug is eligible for coverage under Medicare Part B.We determined that the plan is not required to cover Lidocaine-Prilocaine 2.5%-2.5% cream.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Imbruvica 140 milligram capsules prescribed as first line therapy for mantle cell lymphoma in combination with Rituxan. 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 records show you prescribed Imbruvica 140 milligram capsules to treat the enrollees mantle cell lymphoma in combination with Rituxan as first line therapy. 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.  Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.An oncologist reviewed your appeal and determined that the plan is not required to cover Imbruvica 140 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Corlanor 7.5 milligram tablets. The Part D plan denied the request because the plans prior authorization requirements were not met.  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 indicates that Corlanor has been prescribed for inappropriate sinus tachycardia. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and 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 Corlanor.