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

You requested Nephro-Vite Rx 1 milligram-60 milligram tablets were prescribed for the enrollees chronic kidney disease. The case was auto-forwarded reconsideration by 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 information submitted at the reconsideration level.We determined that the plan is not required to cover Nephro-Vite because it is a prescription vitamin or mineral product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations 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 Sildenafil Citrate 20 mg tablet prescribed to treat erectile dysfunction. The Part D plan denied the request because the drug is not covered under Part D. 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 information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Sildenafil Citrate to treat your erectile dysfunction. Medicare law excludes certain drugs from Part D coverage. Drugs that are 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 plan is not required to cover Sildenafil Citrate 20 mg and it is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligrams/milliliter prescribed for osteoporosis. The Part D plan denied your request for a tiering exception because there is no alternative brand name biologics for the enrollees condition in a lower cost-sharing tier. 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. Prolia is a brand biologic on Tier 4 of the plans formulary. There are no brand 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 cover Prolia at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acitretin 10 milligram capsule twice daily for disorder of the skin and subcutaneous tissue. The Part D plan denied the drug because it was not medically necessary. The plan requires prior approval before covering some 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.Acitretin is being requested to treat a disorder of the skin and subcutaneous tissue. 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 the Acitretin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sublocade prescribed for opioid use disorder. The Part D plan denied your request because there are no conditions under which this drug would be approved under Medicare Part D. 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 reimburse Sublocade as it is excluded from Medicare Part D 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 Nuedexta 20 milligram capsules for pseudobulbar affect. 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 submitted documentation indicates your doctor prescribed the drug for pseudobulbar affect due to Alzheimers disease. 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 Alprazolam 0.25 milligram tablets prescribed four times daily for anxiety disorder. The Part D plan denied your request for a 90-day supply because Alprazolam is only allowed 90 tablets per 30 days. 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 information submitted at the reconsideration level. The documentation indicates your doctor prescribed Alprazolam to treat your anxiety disorder. The plan only allows 90 tablets per 30 days for the drug. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover 120 tablets of Alprazolam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol 180 milligram tablet prescribed daily for hyperlipidemia. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physicians representative submitted a statement and medical records. The medical records show the physician had prescribed Nexletol to treat your hyperlipidemia. A Medicare approved compendium supports the use of the requested drug for your condition.However, the records do not show why you cannot take other drugs on your plans formulary for your condition; specifically, Repatha. The physician simply states he cannot take Repatha but did not explain why and there were no medical records to support what had been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

Part D plan denied your request because drugs being used for the treatment of erectile dysfunction are excluded from coverage by Medicare Part D. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We determined that the plan is not required to cover Tadalafil. Drugs prescribed for the treatment of sexual or erectile dysfunction 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 Megestrol Acetate solution, 625 milligrams/5 milliliters prescribed one teaspoon daily for abnormal weight loss and anorexia. The Part D plan denied your request because the diagnoses provided did not meet the requirements of Food and Drug Administration medically accepted indications. 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 Megestrol Acetate solution to treat your abnormal weight loss and anorexia. However, the Medicare approved compendia do not support the use of this drug for your conditions. A physician reviewed your appeal and determined that the plan is not required to cover Megestrol Acetate solution because your diagnoses do not meet the requirements of medically accepted indications per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Repatha 140 milligram/milliliter Sureclick to treat your condition. 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.Repatha 140 milligram/milliliter Sureclick is a biologic drug on Tier 4 of the plans formulary. There are no biologic drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Klonopin 1 milligram tablet prescribed for restless legs syndrome. The Part D plan denied your request to cover this drug at a lower tier cost. The plan indicated this is an approved non-formulary drug and cannot be provided at a lower tier cost. 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 Klonopin was prescribed; however, Klonopin is a non-formulary approved drug and is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the Klonopin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hizentra, 10 grams/50 milliliters, prescribed 20 milligrams subcutaneously for chronic inflammatory demyelinating polyneuritis. The Part D plan denied your request for a formulary exception because no information was received from your doctor. 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 Hizentra for your chronic inflammatory demyelinating polyneuritis. A Medicare approved compendium does support the use of the requested drug for your condition. However, your doctor did not explain why the requested Hizentra is preferred over the plans current covered formulary drugs used to treat your condition. There is no indication your doctor has tried you on covered formulary drugs with documentation of the results or if the drugs would likely cause adverse events and/or would be less effective than the non-formulary drug Hizentra.A physician reviewed your appeal and determined that the plan is not required to cover Hizentra because the medical records do not indicate why the non-formulary drug is preferred over current drugs on the plans formulary to treat your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Aubagio 14 milligram tablet to treat multiple sclerosis. 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.Aubagio 14 milligram tablet is a brand drug on a specialty tier, tier 5 of the plans formulary.  Drugs on the plan's specialty tier are not eligible for a tiering exception. Therefore, Aubagio is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxycodone HCL 5 milligrams prescribed as directed for pain related to spinal fissures and cancer. The Part D plan denied your request because the approved safety and appropriate prescribing criteria were not met. 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 information submitted at the reconsideration level. The record shows the prescribing physician is not participating in this opioid management program. Also, the plan has placed a restriction on all opioid prescriptions. Therefore, the drug cannot be considered for payment under the Part D benefit.The physician reviewer also determined that the plan is not required to cover the Oxycodone HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Gel 20.25 milligram/actuation for the diagnosis of an endocrine disorder. The Part D plan denied the request due to the medication is not approved by the food and drug administration or supported by a Medicare approved drug compendia for the enrollees condition. 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 also researched Medicare regulations and Medicare approved compendia. The prescriber initially provided the diagnosis of unspecified endocrine disorder. In a statement dated February 1, 2021, the prescriber amended the diagnosis to hypogonadism. Relevant medical records were requested to support the appeal but were not provided. Safety and efficacy of testosterone products in patients with age-related hypogonadism (also referred to as late-onset hypogonadism) have not been established. 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 your 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 Testosterone Gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 7.5 milligram tablet prescribed twice daily to treat congestive heart failure. The Part D plan denied the request for a tiering exception because criteria for the tiering exception was not met. 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.Corlanor 7.5 milligram tablet is a brand drug on Tier 4 of the plans formulary. The prescriber statement indicates that you have tried Spironolactone and Lasix that caused dizziness and diarrhea. The plan requires that all alternative drugs on the plans lower tier are tried or that the prescriber explains why these drugs would not be as effective as the requested drug. However, the prescriber has not indicated that you have tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  Therefore, criteria for the drug was not met 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 Levalbuterol 1.25 milligrams/3 milliliter nebulizer solution prescribed as directed for asthma. 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 an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Levalbuterol 1.25 milligrams/3 milliliter nebulizer solution to treat your asthma. However, we determined that the drug is not eligible for Part D coverage. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. 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 Levalbuterol 1.25 milligrams/3 milliliter nebulizer solution because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit.You may wish to submit a request for Levalbuterol 1.25 milligrams/3 milliliter nebulizer solution to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Daliresp, 250 micrograms prescribed one tablet daily for chronic obstructive pulmonary disease. Your 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 records submitted at the reconsideration level. Your medical records show your doctor prescribed Daliresp to treat your chronic obstructive pulmonary disease. The Medicare approved compendium does support the use of this drug for your condition. However, your medical records do not show that you have tried and failed the required criteria set forth by Medicare.A physician reviewed your appeal and determined that the plan is not required to cover Daliresp because the conditions of coverage have not been met per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zetia, 60 milligrams prescribed one tablet daily for hyperlipidemia. 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 Zetia for your hyperlipidemia. 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 Zetia 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 Vascepa 1 gram capsule, prescribed to treat mixed hyperlipidemia.   The provided diagnosis is a non-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 Vascepa for treatment of your mixed hyperlipidemia.  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 your 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 Vascepa because you do not have a medically accepted indication per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trelegy Ellipta to treat chronic obstructive lung disease. The Part D plan did not provide a timely redetermination decision. 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 information submitted at the reconsideration level.Trelegy Ellipta is a brand drug on Tier 3 of the plans formulary. It is medically indicated for the enrollees diagnosis. However, there are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our Physician Reviewer's opinion is that tiering exception criteria are not met.