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

At issue is Linzess 290 microgram capsules prescribed daily for chronic constipation. The Part D plan denied your request for a tiering exception. 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. Linzess 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. 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 Invega Sustenna Suspension Prefilled Syringe to treat schizophrenia. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.Invega Sustenna is a brand drug on Tier 4 of the plans formulary. The prescriber has not indicated why 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 your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nourianz 20 milligram tablets. The Part D plan denied your request because the medication was not included on the plans formulary and 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 documentation supports that Nourianz has been prescribed in the management of the enrollees Parkinson's disease. However, the prescriber has not sufficiently addressed why all alternative drugs included in the plan to treat this condition have been tried and failed or would likely not be as effective as the requested drug or would likely cause adverse reactions or other harm. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide EC 3 milligram capsules prescribed for the treatment of autoimmune enteropathy. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnoses 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 the enrollees 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 Budesonide EC because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Cyclophosphamide 50 milligram capsules prescribed for polyarteritis nodosa and vasculitis. 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 Cyclophosphamide for polyarteritis nodosa with vasculitis.In review of the Medicare approved compendia, your condition is not a medically accepted indication for Cyclophosphamide. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Cyclophosphamide at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zioptan 0.0015% eye drops prescribed as directed to treat primary open-angle glaucoma. The Part D plan denied your request because the documentation did not support an off-formulary exception and because the quantity limit requested is higher than what the plan allows. 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 record shows that your doctor prescribed Zioptan eye drops to treat your condition. Your medical records do not show that all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. The quantity requested, 180 vials per 90 days exceeds the amount needed to satisfy the prescriber's dosing schedule.A physician reviewed your appeal and determined that the plan is not required to cover the Zioptan eye drops because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 100 mg tablets to treat benign prostatic hyperplasia without lower urinary tract symptoms.  The Part D plan denied the request stating that 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate mofetil 500 milligram tablets prescribed as directed for pemphigus foliaceous. 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 Mycophenolate mofetil for pemphigus foliaceous. 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 Mycophenolate mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symbicort 160-4.5 micrograms inhaler. The Part D plan denied your request. We received an expedited 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 documentation shows Symbicort is prescribed to treat chronic cough. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s). 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 cover Symbicort.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Emgality solution 120 milligram\milliliter pre-filled syringe prescribed daily for chronic migraine without aura, intractable, without status migrainosus. 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 Emgality 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 Emgality.
Appeal type: Prescription Drug
Decision: Unfavorable

 At issue is Nerlynx 40 milligram tablets to treat breast cancer. The Part D plan denied the request. 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 indicated this drug would not be used in combination with Capecitabine. Therefore, the prior authorization requirements were not met.   Our Physician Reviewer determined that the plan is not required to cover Nerlynx.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dilantin 100 milligram capsules prescribed twice daily for seizures. The Part D plan denied your request for a tiering exception. 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. Dilantin 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. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Testosterone 1.62% gel. The Part D plan denied the request stating that the medication was prescribed for a non-medically accepted indication. 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 documentation indicates that Testosterone is being prescribed for hypogonadism. However, the physician has not specified whether the enrollee is being treated for primary, hypogonadotropic, or late-onset hypogonadism. The Medicare approved compendia do not support using testosterone to treat late-onset (age related) hypogonadism. Therefore, it is not possible to determine if the medication is being prescribed for a medically-accepted indication, and 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 Testosterone gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 1.5 milligram capsules prescribed for anxiety and depression. The Part D plan denied your request for a tiering exception because there were no brand drugs of the same type on the lower cost sharing tiers. 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. Vraylar 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 Hetlioz 20 milligrams prescribed daily for non-24 hour sleep-wake disorder. The Part D plan denied coverage because the plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an 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 records submitted at the reconsideration level. Your medical records show your doctor prescribed Hetlioz 20 milligrams daily for non-24 hour sleep-wake cycle. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records 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 the Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate 2.5 milligrams per 3 milliliter vials prescribed for 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 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 the doctor prescribed Albuterol Sulfate for chronic obstructive pulmonary disease. However, this drug is eligible for coverage under Medicare Part B. Medicare Part B covers this drug for chronic obstructive pulmonary disease, when used with a nebulizer in the home (or in an assisted living facility). Medicare Part D cannot pay for drugs that are covered by Medicare Part B.We determined that the plan is not required to cover Albuterol Sulfate 2.5 milligrams per 3 milliliter vials.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tremfya 100 milligram/milliliter syringe prescribed for plaque psoriasis. 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 physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Tremfya.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Rasuvo 25 milligrams per 0.5 milliliter auto-injector for rheumatoid arthritis. 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.This drug is being 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Azathioprine 50 milligrams prescribed for chronic bronchiolitis and hypersensitivity pneumonitis. 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 Azathioprine for chronic bronchiolitis and hypersensitivity pneumonitis. In review of the Medicare approved compendia, chronic bronchiolitis and hypersensitivity pneumonitis is not a medically accepted indication for Azathioprine. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Azathioprine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 60 milligram capsules prescribed for attention deficit hyperactivity disorder. 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 physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Vyvanse.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sivextro 200 milligram tablets prescribed for disseminated mycobacterium haemophilus and mycobacterium avium complex. 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 your doctor prescribed Sivextro for disseminated mycobacterium haemophilus and mycobacterium avium complex. 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

At issue is Livalo 4 milligrams prescribed as directed for hypercholesterolemia. The Part D plan denied the request for an off-formulary exception. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber was asked questions to clarify the medical history and to provide medical records to support the noted diagnosis. The prescriber was also asked questions to address the plans formulary alternatives. We did not receive the documentation requested.Your medical records do not support a diagnosis nor show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover Livalo because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine/Dextroamphetamine 10 milligram tablets prescribed for hypersomnia. The Part D plan denied your request because drug 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 documentation shows you were prescribed Amphetamine/Dextroamphetamine for hypersomnia. In review of the Medicare approved compendia, hypersomnia is not a medically accepted indication for Amphetamine/Dextroamphetamine. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Amphetamine/Dextroamphetamine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligrams prescribed for palmoplantar psoriasis. 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. We asked you to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The records show you prescribed Otezla to treat the enrollees palmoplantar psoriasis. However, the Medicare approved compendia do not support the use of this drug for this condition. We did not received additional medical documentation to support a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Otezla. We cannot consider a formulary exception for a drug the Part D plan cannot cover.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Morphine Sulfate ER 20 milligram capsule prescribed twice daily for chronic pain syndrome. 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 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 asked you to send us a prescriber statement and information regarding the enrollees 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 for the enrollee. However, we did not receive the documentation.A physician reviewed your appeal and determined that the plan is not required to cover Morphine Sulfate ER 20 milligram capsule.