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

At issue is Valtrex 500 milligrams prescribed as directed for prevention of cold sores. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the Plans formulary exception criteria. A response from the prescriber was not received.Therefore, based upon the current record, 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 Myrbetriq ER 50 milligram tablets prescribed daily for urinary urgency and nocturia. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Myrbetriq ER 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. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Dexilant DR 60 milligram capsule prescribed three times a day to treat gastro-esophageal reflux disease without esophagitis and gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read 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.Dexilant DR 60 milligram capsule is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Stelara 45 milligram\0.5 milliliter injection prescribed as directed for hidradenitis suppurativa. The Part D plan denied your request because the drug is not a medically accepted indication. 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. Your medical records show your doctor prescribed Stelara to treat your condition. 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 Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Olmesartan Medoxomil 40 milligram tablet prescribed daily for hypertension. The Part D plan denied your request for a tiering exception. We received a reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The record shows Olmesartan Medoxomil, a Tier 3 drug, is prescribed to treat your hypertension. Your doctor indicated you had adverse laboratory results using two drugs on the plans formulary. However, the documentation submitted is insufficient to determine why the additional alternative drugs in the lower tiers would not be just as effective for your condition. A physician reviewed the appeal and determined that the plan is not required to cover Olmesartan Medoxomil the alternative drugs have not been determined to be ineffective for your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Diclofenac Epolamine 1.3 percent topical system prescribed daily for low back pain. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The documentation indicates you were prescribed Diclofenac Epolamine 1.3 percent topical system for low back pain.In review of the Medicare approved compendia, low back pain  is a medically accepted indication for Diclofenac Epolamine 1.3 percent topical system if the pain is acute. The record indicates the enrollee was using this drug since December 2019, for back pain, and therefore it would be considered chronic. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Diclofenac Epolamine 1.3 percent topical system at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Visbiome probiotic 900 billion powder pack prescribed for the treatment of diverticulitis. The plan denied the request because Medicare excludes over-the-counter drugs from Part D coverage. 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.According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover Visbiome probiotic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed for circadian rhythm sleep disorder. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted at the reconsideration level. The prescriber did not respond to a request for additional information. Therefore, the prior authorization requirements could not be evaluated.   A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz 5 milligram tablets prescribed daily for alopecia universalis. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Xeljanz 5 milligram tablets to treat your alopecia universalis. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diovan 160 milligram tablets prescribed daily for hypertension. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited 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. Your physician did not submit a supporting statement. A request was made to your physician to address if all formulary alternatives were tried and failed. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Diovan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Toprol XL 100 milligram ER tablets prescribed daily for hypertension. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited 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. Your physician did not submit a supporting statement. A request was made to your physician to address if all formulary alternatives were tried and failed. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Toprol XL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligrams/milliliter injection pen prescribed as directed for coronary artery disease. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The requested drug is being provided by your plan under a formulary exception. Repatha 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 are not eligible for a tiering exception.    A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pemazyre 9 milligram tablets for malignant neoplasm of connective and soft tissue, unspecified. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited 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 submitted documentation indicates Pemazyre was prescribed for malignant neoplasm of connective and soft tissue, unspecified with a primary site of the right deltoid region. Analysis of the tumor, a metastasis to the lung, had genomic findings equivocal for FGFR3. The The Medicare approved compendia do not support the use of this drug for the enrollees condition. Coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover Pemazyre.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% gel pump prescribed for male hypogonadism. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited 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  physician submitted a supporting statement. The documentation indicates the physician had prescribed Testosterone gel for male hypogonadism. However, the records do not show why the enrollee cannot take all drugs on the plans formulary for their condition. The physician did not indicate all alternatives to treat the enrollee's condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Testosterone gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 200 milligram tablets prescribed daily for hypersomnia due to Alzheimers disease. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received an expedited 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Modafinil 200 milligram tablets to treat your hypersomnia due to Alzheimers disease. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.  A physician reviewed your appeal and determined  that the plan is not required to cover Modafinil because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus 5 milligram capsules prescribed for kidney transplant. The Part D plan denied the request because the enrollee was eligible for Medicare Part B coverage at the time of transplant and therefore, the drug was eligible under Part B. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is not required to cover the Tacrolimus. Medicare records indicate the enrollee received a kidney transplant on June 14, 2018, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Tacrolimus is eligible under Medicare Part B. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine HCl 8 milligram sublingual tablets prescribed for chronic pain syndrome. The Part D plan did not complete their review timely. We received an expedited auto-forwarded reconsideration request from the coverage level. 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 indicates your doctor prescribed Buprenorphine HCl 8 milligram sublingual tablets for chronic pain syndrome. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tolterodine Tartrate ER 4 milligram capsules to treat stress incontinence related to overactive bladder. The Part D plan denied your request for a tiering exception. We received an expedited 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. Tolterodine Tartrate ER is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated why other 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, a tiering exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Tolterodine Tartrate ER.
Appeal type: Prescription Drug
Decision: Favorable

You requested Calcitriol 25 micrograms prescribed one capsule daily for low blood calcium levels due to the removal of your parathyroid. The Part D plan denied your request because the drug should be covered under Medicare Part B since you were on dialysis. We received an expedited 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. Your medical records dated March 11, 2021, show your doctor prescribed the requested drug to treat your low calcium levels after the removal of your parathyroid. In addition, the medical records state you have not been on dialysis since June 21, 2019. The Medicare approved compendium supports the drug at issue used to treat your condition.A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hyzaar 12.5 milligram/50 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue was covered as a formulary exception and was not eligible for a tiering exception. We received an expedited 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.Hyzaar is a non-formulary brand drug. Non-formulary drugs are 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

At issue is Bystolic 10 milligram tablet prescribed for major essential hypertension. The plan denied the appeal because there are no brand name drugs of the same type in the lower cost-sharing tiers that treat 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.Your medical records show your doctor prescribed Bystolic for your essential hypertension. A Medicare approved compendium supports the use of the requested drug for your condition. However, Bystolic is a brand name drug on Tier 4 of your plan's formulary. There are no brand name drugs of the same type in the lower cost-sharing levels. Therefore, the requested drug is not eligible for a cost-sharing tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Bystolic because there are no brand name drugs of the same type in the lower cost-sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lynparza 150 milligram tablet prescribed for metastatic gastric cancer with ATM mutation. The Part D plan denied your request because the medication is not prescribed for a medically accepted indication. 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 records show you prescribed Lynparza as monotherapy to treat the enrollees stage IV metastatic gastric cancer. However, the Medicare approved compendia and Medicare Approved journal articles do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Lynparza 150 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica CR 165 milligram extended release tablet prescribed daily for the enrollees idiopathic peripheral autonomic neuropathy. The Part D plan denied coverage because the prior authorization criteria was not met. If prior approval is not obtained, the plan may not cover the drug. 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 records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees condition. However, the enrollees diagnosis does not satisfy the plan's prior authorization coverage criteria. The enrollee must have a covered diagnosis and has experienced an inadequate treatment response, intolerance, or contraindication to Gabapentin.A physician reviewed your 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 Xarelto 20 milligram oral tablet prescribed daily for paroxysmal atrial fibrillation.   The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Xarelto 20 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception. Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Estriadol compound 0.1 milligram capsule. The Part D plan denied your request. 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. This drug is a compounded drug. Therefore, we reviewed each ingredient individually. The ingredients of the requested drug are: Estriadol and coconut. The records show Estadiol compound capsules are composed from bulk power. Drugs compounded from Bulk powders are not Food and Drug Administration approved. The coconut oil does not require a prescription and can be purchased over the counter. Medicare Part D does not cover non-prescription drugs. Therefore, the Estriadol and coconut oil ingredients are not eligible for Part D coverage. Compounded medications that do not contain at least one ingredient that meets the definition of a Part D drug are excluded from coverage.