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

You requested Testosterone 1.62 percent gel pump to treat hypogonadism unspecified. 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. 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 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 Testosterone 1.62 percent gel pump because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Armour Thyroid 90 milligram tablets prescribed daily for hypothyroidism. The Part D plan denied your request because the medication was not Food and Drug Administration approved. 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 you were prescribed Armour Thyroid for hypothyroidism. In review of the Medicare approved compendia, it is noted that Armour Thyroid is not approved by the Food and Drug Administration. Therefore, it does not meet the definition of a Part D drug and cannot be considered for a formulary exception. The plan is not required to cover the Armour Thyroid at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle libre 14 day sensor prescribed by your doctor for diabetes. The Part D plan denied your request because this drug does not meet the definition of a Part D drug. 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 Freestyle libre 14 day sensor because it is not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to 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 coverage for hydrocodone polistirex and chlorpheniramine polistirex 10/8 milligrams per 5 milliliter oral suspension, extended release prescribed daily for cough and cold symptoms. The Part D plan denied your request because the medication is excluded from coverage under Part D. 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 you were prescribed hydrocodone polistirex and chlorpheniramine polistirex oral suspension for cough and cold symptoms. Medicare Part D cannot cover drugs used in the treatment of cough and cold symptoms. Therefore, it is excluded from coverage under Part D. The plan is not required to cover the hydrocodone polistirex and chlorpheniramine polistirex oral suspension at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nourianz 20 milligram tablet prescribed one tablet daily for Parkinsons disease. The plan denied the appeal because this drug is not listed on your formulary plan and alternative drugs on the plan were not tried and failed. 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 Nourianz for your Parkinsons disease. This drug is not listed in your plans formulary for your condition. Your doctor did not indicate that you tried drugs listed on your plans formulary for your condition and why they did not work or that they caused adverse effects. Therefore, the requested drug cannot receive a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Nourianz because the documentation does not show that you have met the coverage criteria for a formulary exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Anoro Ellipta (Umeclidinium Bromide/Vilanterol Trifenatate) 62.5-25 micrograms prescribed one inhalation twice daily for chronic obstructive pulmonary disease. The plan denied the appeal because this drug is not listed on your formulary plan (non-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. Your medical records show your doctor prescribed Anoro Ellipta for your chronic obstructive pulmonary disease. This drug is not listed in your plans formulary for your condition. Your medical records did not indicate that you tried drugs listed on your plans formulary for your condition, why they did not work, or what adverse effects they caused. Therefore, the requested drug cannot receive a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Anoro Ellipta because the documentation does not show that you have met the coverage criteria for a formulary exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate hydrochloride ER 20 milligram tablets prescribed as directed for major depressive disorder. 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. The medical records show the doctor prescribed Methylphenidate hydrochloride ER for major depressive disorder. 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 Methylphenidate hydrochloride ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Remicade 100 milligrams/vial intravenous solution prescribed for Crohns disease. 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. 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 prescriber statement indicates the enrollee has failed treatment with some of the medications on the plans formulary. However, the documentation does not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Remicade.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine Pamoate 50 milligram capsules prescribed for generalized anxiety disorder. 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. 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 do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Hydroxyzine Pamoate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Repatha Sureclick Auto Injector, 140 milligrams/milliliter to treat hyperlipidemia. The Part D Plan denied the request because your prescriber did not provide the detailed information that is required in order to approve the request for a formulary exception. 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 Repatha Sureclick Auto Injector to treat your hyperlipidemia. The Medicare compendia approve the use of Repatha Sureclick for your condition. Your doctor has not provided detailed medical records indicating why all alternatives required by the plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rytary 23.75 milligram/95 milligram capsules prescribed five times daily for Parkinsons disease. 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.Rytary 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 ZTlido 1.8% topical patches prescribed as directed for chronic pain syndrome, fibromyalgia, pain of the left knee and lower leg, and neuropathic pain. 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. The documentation shows the doctor prescribed ZTlido patches for chronic pain syndrome, fibromyalgia, pain of the left knee and lower leg, and neuropathic pain. However, the Medicare approved compendia do not support the use of this drug for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to cover ZTlido patches.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate hydrochloride ER 36 milligram tablets prescribed as directed for fatigue. 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. The prescriber statements show the doctor prescribed Methylphenidate hydrochloride ER for fatigue and daytime drowsiness related to anti-seizure medication. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A letter from the enrollee is acknowledged.A physician reviewed your appeal and determined that the plan is not required to cover Methylphenidate hydrochloride ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Raloxifene Hydrochloride 60 milligram tablets. The Part D Plan denied your request for a tiering exception. 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. Raloxifene Hydrochloride 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 tier exception for Anoro Ellipta inhalation 62.5 micrograms per 25 micrograms once daily prescribed daily for chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception because Anoro Ellipta is a brand name Tier 3 drug and there are no drugs on lower tiers 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. We also researched Medicare systems and reviewed the enrollment data available. The record shows Anoro Ellipta is being prescribed for chronic obstructive pulmonary disease. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Anoro Ellipta 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

At issue is Trulance 3 milligram tablets prescribed. 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 auto-forwarded reconsideration request from the plan.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. 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.The plan requires an intolerance or contraindication to Lactulose and Linzess 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 Trulance. Medical necessity was not established.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Disopyramide 100 milligram capsules for the treatment of chronic heart failure. The Part D plan denied your request for a formulary exception 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 documentation shows Disopyramide was prescribed for chronic heart failure. 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 Disopyramide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rytary ER 23.75/95 milligram capsules prescribed for Parkinsons disease. The Part D plan denied your request for a tier change request because Rytary is in the specialty tier of your list of covered drugs. 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. The record shows Rytary is being prescribed for Parkinsons disease. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Rytary is a brand name Tier 4 drug. Your plan does not allow you to receive drugs in this tier at a lower cost share.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcitriol 0.25 microgram capsules prescribed daily for secondary hyperparathyroidism. The Part D Plan denied your request for a tiering exception because there are no lower cost sharing alternatives. 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. Calcitriol 0.25 microgram capsule is a generic drug on Tier 2 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

At issue is Hizentra 4 grams/20 milliliter injections every week for non-familial hypogammaglobulinemia. The Part D plan denied your request for a formulary exception 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 documentation shows Hizentra was prescribed for non-familial hypogammaglobulinemia. Medical records support the diagnosis of common variable immunodeficiency with low levels of IgG. Hizentra is a medically accepted indication for this condition. However, the prescriber has not indicated 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 coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.A physician reviewed your appeal and determined that the plan is not required to cover Hizentra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine 2 milligram/Naloxone 0.5 milligram sublingual film prescribed daily for lumbar radiculopathy. The Part D plan denied your request because the provided diagnosis is a non-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 medical records show Buprenorphine 2 milligram/Naloxone 0.5 milligram sublingual film was prescribed to treat chronic lumbar radiculopathy. However, the Medicare approved compendia do not support the use of this drug for this condition. 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.A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine 2 milligram/Naloxone 0.5 milligram sublingual film.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vascepa, 1 gram capsules prescribed twice daily for prevention of cardiovascular events. The Part D plan denied your request because the drug was not used 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Vascepa to treat prevention of cardiovascular events. However, the medical records provided, including the laboratory reports received at reconsideration, do not support a medically accepted indication for Vascepa in the Medicare approved compendia for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 120 milligram tablets prescribed for schizoaffective disorder, bipolar type. The Part D plan denied your request for a tier change request because Latuda is in the specialty tier of your list of covered drugs. 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. The plan shows Latuda is a brand name Tier 5 drug. Your plan does not allow you to receive drugs in this tier at a lower cost share.Therefore, the requested drug is not eligible for a tiering exception.