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

At issue is Movantik 25 milligram tablets prescribed to treat chronic idiopathic constipation and abdominal pain. 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. Movantik 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.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 Cyclobenzaprine Hydrochloride 10 milligram tablet prescribed daily for lumbar disc degeneration and muscle spasms. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Cyclobenzaprine Hydrochloride to treat the enrollees chronic conditions. The Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Deferiprone 500 milligram tablet, two tablets prescribed three time daily for hereditary hemochromatosis. 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 your doctor prescribed Deferiprone to treat your hereditary hemochromatosis. However, the Medicare approved compendia do not support the use of this drug for your condition due to not being related to thalassemia syndromes or hematologic disorders requiring chronic transfusion therapy. A physician reviewed your appeal and determined that the plan is not required to cover Deferiprone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Aptiom 400 milligram tablets prescribed for seizure disorder. 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. Aptiom is included in Tier 5 of the plans formulary, which is the tier for specialty drugs. The plan does not grant tiering exceptions for specialty drugs. Therefore, this drug is not eligible for coverage at a lower-cost tier. A physician reviewed your appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sirolimus 1 milligram tablet prescribed for complex immune dysregulation disorder characterized by CTLA-4 haploinsufficiency, common variable immune deficiency, inflammatory bowel disease, and genetic susceptibility to other disease. 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 your doctor prescribed Sirolimus to treat your complex immune dysregulation disorder characterized by CTLA-4 haploinsufficiency, common variable immune deficiency, inflammatory bowel disease, and genetic susceptibility to other disease. 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 Sirolimus .
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Epolamine Patch 1.3% to treat cervical disc displacement, right shoulder pain, radiculopathy of the cervicothoracic region, and complex regional pain syndrome of the right upper limb. 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 your doctor prescribed Diclofenac Epolamine Patch 1.3% to treat your cervical disc displacement, right shoulder pain, radiculopathy of the cervicothoracic region, and complex regional pain syndrome of the right upper limb. 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 Doclofenac Epolamine Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Novolog 100 unit/milliliter injection solution prescribed for insulin dependent diabetes. We received an 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.Novolog is a brand biologic on Tier 2 of the plans formulary. There are no biologics of the same type on the lower cost sharing tiers. Therefore, this biologic 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 coverage for Estradiol 0.05 milligram per 24 hour weekly transdermal patches prescribed for postmenopausal atrophic vaginitis. 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 Calcitriol 0.25 microgram capsules prescribed for secondary hyperparathyroidism. 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. Calcitriol 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

You requested Corlanor 7.5 milligram tablets prescribed for postural orthostatic tachycardia syndrome. 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 your doctor prescribed Corlanor to treat your postural orthostatic tachycardia syndrome. 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 Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone Cypionate 200 milligram/milliliter injection prescribed for testicular hypofunction. 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 your doctor prescribed Testosterone Cypionate for testicular hypofunction. However, 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. Per the compendia, The safety and efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism. 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 Testosterone Cypionate.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Budesonide 0.5 milligram per 2 milliliter suspension vials for treatment of chronic sinus congestion (rhinitis). The Part D plan denied the request stating that the medication was coverable under Medicare Part B since it was being used with a nebulizer.  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 prescriber has noted at reconsideration that the Budesonide suspension is not being used in a nebulizer. The prescriber states that the Budesonide suspension is being used by the enrollee in nasal rinses due to chronic sinus congestion (rhinitis). Treatment of rhinitis, both allergic and non-allergic is a medically accepted indication. Although the formulation requested is typically used in a nebulizer, it is not required to be used as such. Per Medicare guidance, Budesonide solution for inhalation, not being used by nebulizer, but being used for nasal irrigation is paid under Part D.  Medicare guidance stated, It is the route of administration, not the mode of administration that matters.A physician reviewed your appeal and determined that the plan is required to cover the Budesonide 0.5 milligram per 2 milliliter suspension vials.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed daily for circadian rhythm sleep disorder, free-running type (non-24). 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 called the prescriber to request information regarding your condition and the requested drug. Specifically, we were told that the requested drug has been changed. In addition, 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine 10 milligram tablets prescribed for lumbar muscle spasms. 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 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 doctors statement shows Cyclobenzaprinewas prescribed to treat your lumbar muscle spasms. An additional diagnosis of bone spur was submitted at reconsideration. Per the compendia, Use caution or avoid use as potentially inappropriate in older adults. We did not received medical records to support the diagnosis submitted or an explanation why a safer medication would be less effective.A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aminocaproic Acid 1000 milligram tablet prescribed for abnormal fibrinolysis. 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 your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you.  However, we did not receive medical records.The doctors statement shows Aminocaproic Acid was prescribed for abnormal fibrinolysis. 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 Aminocaproic Acid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 100 milligram tablet prescribed 90 tablets for 30 days for chronic migraine without aura, not intractable, without status migrainosus.   The Part D plan denied the request.  The requested drug is not on the plans formulary. 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 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 Durezol 0.05 percent drops prescribed for endogenous anterior uveitis, both eyes. 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. This drug is provided by the plan under a formulary exception. It 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 the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sodium chloride .9% solution vial prescribed for malignant neoplasm of conjuctiva. 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 record shows that the requested Sodium chloride is an ingredient within a compounded drug in which one or more of the ingredients is covered under Medicare Part B. Medicare Part D does not cover drugs that do not meet the definition of a Part D drug. Therefore, we determined that the plan is not required to cover or reimburse for the Sodium chloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colesevelam 3.7gram Packet to treat bile acid malabsorption. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.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 Lovaza 1 gram capsules prescribed for mixed hyperlipidemia. The Part D plan denied your 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 submitted a supporting statement. The supporting statement did not indicate that you have tried one of the formulary alternatives and that it was ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Lovaza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuplazid 34 milligram capsules prescribed for hallucinations and Parkinsons disease. 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. Nuplazid is a brand name drug on Tier 4 of the plans formulary. There are no brand name 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 Hyoscyamine Sulfate 0.125-milligram sublingual tablet prescribed for abdominal pain. The Part D plan denied your 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 Hyoscyamine Sulfate because it is not an approved Food and Drug Administration drug. A covered Part D drug must be approved by the Food and Drug Administration. 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 Fioricet with codeine 50-300-40-30 milligrams capsule to treat low back pain and chronic pain. 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 your doctor prescribed Fioricet with codeine 50-300-40-30 milligrams capsule to treat low back pain and chronic pain. However, the use of the requested drug to treat the provided diagnoses is an off-label use. 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 Fioricet with codeine 50-300-40-30 milligrams capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 50-milligrams to treat sexual dysfunction. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not FDA approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.A physician reviewed the appeal and determined that the requested drug is excluded from Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Caplyta 42 milligram capsules prescribed for bipolar disorder. 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 your doctor prescribed Caplyta to treat your bipolar disorder. 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 Caplyta.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Pregabalin 75 milligram capsule to treat neuropathic pain in an enrollee with a history of spinal stenosis and spondylosis status post recent right C7-T1 posterior foraminotomy.   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.Drugdex cites results from the following reference in the FDA Use section Neuropathic pain-spinal cord injury:  Finnerup NB, Attal N, Haroutounian S, et al: Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol 2015; 14(2):162-173, which concluded that Pregabalin is one of several drugs proposed as a first line treatment of neuropathic pain.  The enrollees condition is included in the patient population of studies cited. Therefore, this drug is being prescribed for a medically accepted indication.  The prescriber also states that the enrollee has experienced an inadequate treatment response to Gabapentin. The documentation does not satisfy the plans coverage criteria.  Therefore, an exception to the plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.