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

You requested Restasis eye drops prescribed as directed for severe dry eyes. The Part D plan denied the 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. We also researched Medicare systems and reviewed the enrollment data available.The record shows you were prescribed Restasis eye drops for severe dry eyes. However, the Medicare approved compendia do not support the use of this drug for your condition. The request for a tiering exception was not reviewed. We cannot consider a tiering exception for a drug that is not eligible for Part D coverage. 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 the Restasis eye drops because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Raloxifene 60 milligram tablet prescribed daily for osteopenia and gastroesophageal reflux disease. The Part D plan denied a request for a tiering exception because you did not have a medically accepted indication for this drug. 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 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 the enrollees condition.  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 Raloxifene.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine HCL 10 milligram tablet prescribed three times day for lumbar post-laminectomy syndrome. The Part D plan denied a request for coverage because you did not have a medically accepted indication for this drug. 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 Cyclobenzaprine was prescribed to treat lumbar post-laminectomy syndrome. A prescriber statement also indicates for skeletal muscle spasm and that the enrollee has been on this drug since 3/28/2014. However, the Medicare approved compendia does not support the use of this specific drug for the enrollees condition(s).A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine.
Appeal type: Prescription Drug
Decision: Unfavorable

You prescribed Restasis 0.05% by droperette twice daily for dry eye syndrome. 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.Restasis is a brand drug on Tier 3 of the Plans formulary. The enrollee was being treated for dry eye syndrome. However, 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. There are no lower tiered brand drugs of the same type to treat the enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Restasis.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 0.1% ointment prescribed to treat bullous pemphigoid. The Part D plan denied your request because the medication is 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 records show you prescribed Tacrolimus 0.1% ointment to treat the enrollees bullous pemphigoid. However, the Medicare approved compendia 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 Tacrolimus 0.1% ointment. We cannot consider prior authorization approval for a drug the Part D plan cannot cover.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24-26 milligram tablets prescribed twice daily for cardiomyopathy with reduced ejection fraction. The Part D plan denied your request for a tiering exception because there is no alternative brand name drugs for the enrollees condition in a lower cost-sharing tier. 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. Entresto 24-26 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 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 cover Entresto at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Orthovisc 30 milligram prefilled syringe prescribed once a week for three weeks for spinal stenosis, lumbar region. The Part D plan denied your request because the drug is excluded from coverage. 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 determined that the plan is not required to cover Orthovisc because it is used for diagnostic or therapeutic purposes in a provider or physician office setting. Nonprescription or over-the-counter drugs are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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

At issue is Combigan ophthalmic solution prescribed as directed. The Part D plan denied your request for a tiering exception because the drug was on the lowest cost share tier allowed by your plan. 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. Combigan 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 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 Hydrocodone Polistirex/Chlorpheniramine Polistirex 8 milligrams/5 milliliter suspension for the enrollees condition. The Part D plan denied your request because cough and cold medications do not meet the definition of Part D drugs. 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 determined that the plan is not required to cover Hydrocodone Polistirex/Chlorpheniramine Polistirex because it was for the symptomatic relief of coughs and colds. Drugs prescribed for symptomatic relief of cough and colds are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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 Gliostine 100 milligram capsule prescribed for glioblastoma. The Part D plan denied your request because the drug was excluded from coverage under Medicare Part D because it is a biologic drug, and its manufacturer has not signed the Medicare Coverage Gap Discount Agreement. 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 record shows Gliostine is excluded from coverage under Medicare Part D because it is a brand drug and its manufacturer has not signed the Medicare Coverage Gap Discount Agreement. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. The manufacturer, NextSource Pharmaceuticals, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Gliostine. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 500 milligram tablets prescribed twice daily for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for a lower cost-sharing tier. 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.Xifaxan is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier 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 Estradiol.0375MG/24 PATCH DSW to prevent post-menopausal osteoporosis. 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. The enrollee does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plans coverage criteria and has not indicated why all alternatives required by the Plan would likely cause harm or not be as effective for the enrollee as the requested drug.  A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Uribel 118 milligram tablets prescribed for dysuria (painful urination). The Part D plan denied your request because the drug at issue was not Food and Drug Administration approved. 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 record shows your physician prescribed Uribel for your dysuria. The drug at issue is not Food and Drug Administration approved. Therefore, the drug cannot be considered a Part D benefit.We determined that the plan is not required to cover the Uribel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dalfampridine 10 milligrams every 12 hours prescribed for unspecified nystagmus. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. 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 show your doctor prescribed Dalfampridine to treat your unspecified nystagmus. 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 Dalfampridine. The Food and Drug Administration has only approved this drug to be used in patients with multiple sclerosis.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Creon DR 36,000 unit capsules prescribed for exocrine pancreatic insufficiency. The Part D plan denied your request for a tiering exception because Creon DR is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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. The record shows Creon DR is being prescribed for exocrine pancreatic insufficiency. The Medicare approved compendia support the use of the requested drug for your condition. The plan shows Creon DR is a brand name Tier 3 drug. There are no brand name 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

You requested Acyclovir 5% topical prescribed for herpes dermatitis. 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 dated 2/4/2021 indicates your doctor initially prescribed the drug for herpes dermatitis and not genital herpes. Upon reconsideration, your doctor indicated the drug was prescribed for genital herpes; however, this diagnosis was not corroborated by medical records. 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

You requested Octreotide 100 micrograms/milliliter subcutaneous injections three times daily for the treatment of cardiomyopathy and recurrent gastrointestinal bleeding. The Part D plan denied your request because the drug was ordered for a non-medically accepted indication. 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 medical records show Octreotide was prescribed for your conditions. However, the Medicare approved compendia do not support the use of this drug for cardiomyopathy or recurrent gastrointestinal bleeding. A physician reviewed your appeal and determined that the plan is not required to cover the requested Octreotide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin ER 10 milligram tablets prescribed twice daily for post laminectomy syndrome. The Part D Plan denied your request for a lower-cost tiering exception because the medication is not included on the plans formulary. 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. A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.Oxycontin ER is not included on your plans formulary. While the plan has approved the request for coverage of the non-formulary medication, a lower-cost tiering exception cannot be approved. The plan does not grant tiering exceptions to non-formulary drugs. Therefore, this drug is not eligible for coverage at a lower-cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Simponi 50 milligrams/0.5 milliliters prescribed every four weeks for ankylosing spondylitis. The Part D plan denied your request because Simponi was previously filled on January 4, 2021, and attempted to be refilled for January 22, 2021, which was too soon. 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 records show you prescribed Simponi to treat your ankylosing spondylitis. This medication has previously been approved for a formulary exception. However, an exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover Simponi early. A physician reviewed your appeal and determined that the plan is not required to cover the Simponi, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vancomycin HCl 125 milligram tablets prescribed for urinary tract infection and prevention of clostridium dificile. The Part D plan denied your request because the drug was 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. Your medical records show your doctor prescribed the requested drug for prevention of a clostridium dificile infection during treatment for a urinary tract infection. However, the Medicare approved compendia do not support the use of this drug for your condition. The drug is not for the prevention of clostridium dificile. Your request for a quantity of medication above quantity limit criteria has not been addressed as the drug was not used for a medically accepted indication.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 Delstrigo 100 milligrams/300 milligrams/300 milligrams prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for a lower cost-sharing tier. 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.Delstrigo is a brand drug on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier 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

You requested Methylphenidate Hydrochloride 5 milligram tablets prescribed for resistant depression. The Part D plan denied your request because the medication is 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 records show you prescribed Methylphenidate to treat the enrollees depression. However, the Medicare approved compendia 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 Methylphenidate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rituxan 500 milligrams/50 milliliters for Lambert-Eaton myasthenic syndrome. 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 your doctor prescribed the drug for Lambert-Eaton myasthenic 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 Zolpidem Tartrate 10 milligram tablets prescribed for the enrollees insomnia. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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 records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of insomnia, which is a medically accepted indication. However, the enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria, as the prescriber did not indicate the enrollee had tried and failed with Ramelteon and Silenor.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.