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

At issue is Mesalamine 1000 milligram suppository prescribed daily for ulcerative colitis. The Part D plan denied your request for a tiering exception because there were no lower tier alternatives for the enrollees condition. 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.Mesalamine suppository is a  generic drug on Tier 4 of the plans formulary. The prescriber statement shows the drug was ordered for the enrollees ulcerative colitis. There are no 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 Rituxan solution prescribed for Non-Hodgkins lymphoma with common variable immunodeficiency. The Part D plan denied your request for this drug due to it possible being dispensed to a physicians service. 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 records indicate Rituxan is an intravenous drug being prescribed to treat Non-Hodgkins lymphoma with common variable immunodeficiency. This drug could be covered under Medicare Part B; therefore, is not eligible to be covered under the Medicare Part D Prescription Drug benefit. A physician reviewed your appeal and determined that the plan is not required to cover Rituxan.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 Gralise 60 milligram tablets three times daily for chronic pain syndrome and post laminectomy syndrome. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates the drug was prescribed for chronic pain syndrome. The Medicare approved compendia do not support the use of this drug for the enrollees 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: Favorable

At issue is Febuxostat 80 milligram tablets to treat gout for an enrollee who was intolerant to Allopurinol. 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.The prescriber has provided office notes and a statement. The prescriber stated that the enrollee did try and was intolerant to Allopurinol due to elevated liver enzymes. The enrollee has tried the alternatives required by the plan. A physician reviewed your appeal and determined that step therapy criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Mupirocin two percent ointment to treat chronic sinusitis. 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.Mupirocin two percent ointment is a generic drug on Tier 2 of the plans formulary. There are no generic drugs of the same type on a lower tier on the plans formulary to treat the same condition. In addition, the provided diagnosis is a non-medically accepted indication for the requested medication. 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

You requested coverage for Buprenorphine HCL 8 milligram sublingual prescribed daily for chronic pain.  The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 Buprenorphine HCL for acquired absence of unspecified leg above knee. In review of the Medicare approved compendia, chronic pain is not a medically accepted indication for Buprenorphine HCL sublingual tablets. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Buprenorphine HCL at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Dexilant DR 60 milligrams prescribed daily for gastroesophageal reflux disease and hiatal hernia. The Part D plan denied your request for a tiering exception because Dexilant is a brand name Tier 4 drug and the lower cost-sharing tiers only contain generic alternative 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 including 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 Dexilant DR is being prescribed for gastroesophageal reflux disease and hiatal hernia. The Medicare approved compendium support the use of the requested drug for your condition. The plan shows Dexilant DR is a brand name Tier 4 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 Savaysa 60 milligrams prescribed daily for atrial fibrillation. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication and did not meet prior authorization requirements. 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 Savaysa for atrial fibrillation. The Medicare approved compendia contains citations that indicate atrial fibrillation is a medically accepted indication for Savaysa. However, there is no indication that this patient has tried the formulary medication Eliquis or Xerlato. Per the plan policy, coverage is provided for atrial fibrillation or flutter if creatinine clearance is less than or equal to 95 milliliters per minute and if the patient has tried Eliquis or Xeralto Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Savaysa at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate 2.5 milligrams per 3 milliliter solution for use in a nebulizer in the home. 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 benefit. We received an expedited 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. We also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug would be eligible for coverage under Part B.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sumatriptan Succinate 100 mg (18 tablets per 30 days) to treat chronic headache. The Part D Plan denied the request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan limits the amount of Sumatriptan Succinate 100 mg to 9 tablets every 28 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the enrollees condition or would be likely to cause harm to the enrollee. Therefore, an exception to the plans coverage criteria is not supported.  Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ztlido patch to treat back pain. The Part D Plan denied the 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.The prescriber has not indicated why all formulary alternatives required by the Plan would likely not be as effective for treat the enrollee's condition.  Provider indicates that patches are not sticking well, but no office notes have been submitted to address this issue. 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

At issue is Vyvanse 30 milligram tablets prescribed for major depressive disorder, recurrent severe without psychotic features and major depressive disorder recurrent, partial remission. The Part D plan denied your request because this drug is not medically accepted, per Medicare rules, for this condition. We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The prescriber submitted a statement that  the enrollee requires this treatment for augmentation strategy for her antidepressant medication as other augmentation strategies have not been successful. However, Medicare approved compendia do not support the use of this drug for depression. Medicare requires that the drug must be prescribed for a medically accepted indication that is approved by the Federal Drug Administration or supported by one or more citations in Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Vyvanse.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Neurontin 100 milligrams, two capsules in the morning and three capsules in the evening, to treat atypical facial pain. The Part D plan denied the request stating that the provided diagnosis is not a medically accepted indication. We received an expedited 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 use of the requested drug to treat the provided condition is an off-label use. The Medicare approved compendia do not support the use of the requested drug, as prescribed, for the treatment of the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Vyvanse 30 milligrams prescribed daily for depression. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 Vyvanse for depression. In review of the Medicare approved compendia, depression is not a medically accepted indication for Vyvanse. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Vyvanse at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xhance nasal aerosol breath activated 93 micrograms/activation to treat allergic rhinitis and chronic sinusitis. 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.Xhance nasal aerosol breath activated 93 micrograms/activation is a brand drug on Tier 3 of the plans formulary. 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.A physician reviewed your appeal and determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tobramycin ampule for inhalation via nebulizer to treat pseudomonas infection in tracheostomy patient. 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. Based on the information provided, we determined the drug would be eligible for coverage under Part B. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Topiramate 25 milligram tablets prescribed twice daily for chronic pain syndrome, low back. The Part D plan denied your request because the medication is not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The records show you prescribed Topiramate to treat the enrollees low back pain. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Topiramate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Temazepam, 15milligram capsule prescribed one before bedtime for insomnia. Your Part D plan denied the appeal because a prior authorization was not submitted. A lower cost share exception could not be approved for the requested drug because the prior authorization requirements were not met. 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 asked your doctor to send us information regarding your condition. We did not receive the requested documentation. The prescriber has not sufficiently addressed the Plans coverage criteria. As such, the plan cannot provide coverage, and a tiering exception cannot be considered for the requested drug.A physician reviewed your appeal and determined that the plan is not required to cover this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsule to treat non-24-hour sleep-wake disorder. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or has not indicated why all alternatives required by the plan would likely cause harm or not be as effective for the enrollee as the requested drug. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac sodium 3 percent gel prescribed for lumbago with sciatica and right knee pain. The Part D plan denied your request because it does not meet the criteria of 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 Diclofenac sodium 3 percent gel to treat your lumbago with sciatica and right knee pain. However, the Medicare approved compendia do not support the use of this drug for your 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 Diclofenac sodium 3 percent gel because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium-Albuterol inhalation solution to treat chronic obstructive pulmonary disease. 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.Based on the information provided, we determined the drug would be eligible for coverage under Part B.  A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Colesevelam HCL 625 milligrams prescribed as directed for chronic diarrhea due to no gallbladder. The Part D plan denied the request because it does not meet the criteria of 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 record shows you were prescribed Colesevelam HCL prescribed to treat chronic diarrhea due to no gallbladder. However, the Medicare approved compendia do not support the use of this drug for your 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 the Colesevelam HCL because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Neurontin 300 milligram capsules prescribed three time daily for peripheral neuropathy. The Part D plan denied your request because the medication is 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 records show Neurontin is prescribed to treat peripheral neuropathy. However, the Medicare approved compendia do not support the use of this drug for this condition. There is no indication of what type of peripheral neuropathy at issue. A physician reviewed your appeal and determined that the plan is not required to cover Neurontin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Accu-Chek Guide strips, 400 strips per 90 days prescribed four-times-daily for blood glucose management. The Part D plan denied the request because this product is not eligible for coverage under your Medicare Part D benefit. The product is not on your formulary, is not a drug, and is not considered a medical supply associated with the delivery of insulin to the body. 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 physician states that the Accu-Chek Guide strips are required to be used with your insulin pump. Medicare records support you were enrolled in Part A and Part B Medicare beginning November 1, 1999, to present. The Medicare Part D Prescription Drug benefit does not cover Accu-Chek Guide test strips. We determined that the plan is not required to cover Accu-Chek Guide test strips. Medicare Part B is responsible for the Accu-Chek Guide test strips.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol solution for a nebulizer. 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. Based on the information provided, we determined the drug would be eligible for coverage under Part B under Medicare rules.   A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage. Please submit your request to Medicare Part B.