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

You requested Itraconazole 100 milligram capsules prescribed as directed. We received the case to perform an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.We asked the prescriber to send us a supporting statement and medical records showing the medical necessity of Itraconazole for this enrollee. However, we did not receive the documentation.The record shows the enrollee received Itraconazole. The documentation available for review does not include medical records showing the enrollees condition. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to reimburse the Itraconazole.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tymlos 80 microgram pen injector prescribed as directed to osteoporosis. 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. 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 Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 0.5 milligrams per 2 milliliters suspension prescribed to make a Budesonide slurry to treat the diagnosis of eosinophilic esophagitis. 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 use of the requested drug to treat the provided diagnoses is an off-label use. The Medicare approved compendia do support an orphan drug designation for the use of the requested drug, as prescribed, for the treatment of your condition. However, there are no medical records submitted to support the diagnosis of eosinophilic esophagitis. Therefore, the Medicare Part D plan is not required to cover the Budesonide. A physician reviewed your appeal and determined that the plan is not required to cover Budesonide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Exelon 4.6 milligram 24 hour patch. 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.Exelon 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

At issue is Spiriva respimat 2.5 microgram aerosol solution prescribed as directed to treat chronic pulmonary coccidioidomycosis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. No medical records were provided by the prescriber. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the Spiriva respimat because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prolia 60 milligram/milliliter syringe prescribed for osteoporosis. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We 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 Prolia was prescribed for osteoporosis with a high fracture risk confirmed by a dual energy x-ray absorptiometry scan. However, this drug is eligible for coverage under Medicare Part B. Medicare Part D does not cover a drug that is being billed, dispensed, and administered by the physician in his office or infusion clinic.We determined that the plan is not required to cover Prolia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz 5 milligram tablets prescribed for sarcoidosis and alopecia areata. 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 Xeljanz for sarcoidosis and alopecia areata. 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 Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Leflunomide 10 milligram tablets to treat rheumatoid arthritis. 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.Leflunomide is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated why all 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 grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate to treat erectile 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.Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Testosterone 1% 25 milligram/2.5 gram gel packet to treat hypogonadotropic hypogonadism. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber states the enrollee has loss of muscle mass, low energy, low libido, and weakness. The records include two separate low free testosterone levels drawn on different days. The documentation satisfies the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablets prescribed for postural orthostatic tachycardia syndrome. 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 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Corlanor to treat your postural orthostatic tachycardia syndrome. 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 the Corlanor at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig 140 milligram/milliliter auto-injector prescribed for chronic migraine. 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 all formulary alternatives would be ineffective. Your doctor did not address all formulary alternatives had been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Aimovig.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Upneeq 0.1 % solution. 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.We determined that the plan is not required to reimburse you for the Upneeq. The plans Evidence of Coverage indicates the out-of-network pharmacy criteria were not met. 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

You requested Eliquis 5 milligram tablet prescribed as directed for atrial fibrillation. The Part D plan denied your request for a tiering exception because the drug you requested has been approved as a non-formulary 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 information submitted at the reconsideration level. The record shows you were prescribed Eliquis to treat your condition. Since the drug isnt on the plans formulary it is not eligible for a tiering exception. 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 Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epclusa 400 milligram-100 milligram tablet to treat Chronic Hepatitis C, genotype 1b, in a treatment naive enrollee. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read the documentation submitted. This includes any information submitted at the reconsideration level.We asked the prescriber to send us information regarding the your condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. We received the documentation and included it in our review.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 Zetia 10 milligram tablets prescribed daily for the enrollees condition. 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.Zetia is a brand drug on Tier 3 of the plans formulary. Your doctor submitted a supporting statement. The statement did not address why all alternative lower-tier medication on the plans formulary would not work for you. All brand drugs on lower tiers have not been tried. 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 Onfi 10 milligram tablets to treat seizures related to the diagnosis of Lennox-Gastaut syndrome. 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.Onfi is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain why all alternatives required by the plan (generic equivalent - Clobazam) 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 formaulary exception coverage criteria is not supported. There is conflicting information in the file, a request for information statement of March 16, 2021, indicating generic clobazam is acceptable, and a request for information of March 19, 2021, indicating clobazam has been tried and failed. Pharmacy records indicate generic clobazam has been used previously. Tiering exception issue is not addressed.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 Xyosted Solution Auto Injector 75 milligram/0.5 milliliter prescribed to treat hypogonadism. 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. We also researched Medicare regulations and Medicare approved compendia. The Medicare approved compendia indicates the safety and efficacy of testosterone replacement therapy for men with late-onset hypogonadism have not been established.  A physician reviewed your appeal and determined that the plan is not required to cover Xyosted Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 10-20 milligram capsules prescribed to treat pseudobulbar affect without amyotrophic lateral sclerosis or multiple sclerosis. 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. There is a list of diagnoses and a medically accepted indication is not listed. A medically accepted indication is not supported by medical records.A physician reviewed your appeal and determined that the plan is not required to cover Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig 140 milligram/milliliter auto-injector prescribed for the enrollees condition. 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.Aimovig is a brand biologic drug on Tier 3 of the plans formulary. There are no brand biologic drugs of the same type on the lower cost sharing tiers. Therefore, this biologic 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 Synthroid 50 microgram tablets prescribed for the enrollees condition. 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.Synthroid 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

At issue is Solifenacin Succinate 10 milligram tablets. The Part D plan denied your request for a tiering exception. We received an expedited auto-forwarded 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. Solifenacin Succinate 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. 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 Stelara to treat moderate to severe Crohns disease. 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. This drug is at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Darifenacin Hydrobromide Extended Release tablets. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. There was insufficient medical records submitted. It was unable to be determined if the drug requested was medically indicated for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Darifenacin Hydrobromide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Bactroban 2% Nasal Ointment prescribed for a nasal staph infection. The Part D plan forwarded the request to us.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.Bactroban 2% Nasal Ointment is not included in the plans formulary. A request was submitted to the prescriber to provide a prescriber statement and supporting medical records to address the formulary exception criteria. However a prescriber statement and supporting medical records were not received.  The submitted documentation does not sufficiently address why all alternative medications included in the plans formulary to treat the noted condition 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Forteo 620 microgram per 2.48 milliliter subcutaneous injection pen prescribed for senile osteoporosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The medical records show that Forteo has been prescribed to treat senile osteoporosis. The Part D plan has prior authorization requirements that need to be satisfied prior to covering this medication. We asked the prescribing physician to send us a prescriber statement to address these requirements. However, a prescriber statement was not received, and the submitted medical records do not sufficiently address the plans prior authorization requirements for this medication. A physician reviewed your appeal and determined that the plan is not required to cover the Forteo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Emgality 120 milligram/milliliter injection prescribed to treat migraines.  The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The plan requires prior authorization criteria be met for this drug to be covered. There are no medical records submitted that indicate you have previously tried or have a contraindication to an 8 week trial of Topiramate, Valproic, or Divalproex Sodium. The prior authorization requirements were not met. A physician reviewed your appeal and determined that the plan is not required to cover Emgality.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis 0.05 % ophthalmic emulsion prescribed twice daily for keratoconjunctivitis sicca. 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. Restasis 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.