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

At issue is Pradaxa 150 mg capsule (60/30) to treat atrial fibrillation. 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 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

At issue is Xarelto 15 milligram tablets prescribed daily for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on 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.Xarelto 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 Oxycodone-Acetaminophen, 10-325 milligram tablets, prescribed for chronic back pain. The Part D Plan denied your request for a tiering exception because there were no lower tier alternatives of the same type on the plans formulary. We received an auto-forwarded reconsideration request from the coverage level. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Oxycodone-Acetaminophen at a lower cost tier.Oxycodone-Acetaminophen  is a generic opioid drug on Tier 3 of the plans formulary. There are no generic opioid drugs on the lower cost sharing tiers. There must be a drug of the same type on a lower tier of the plans formulary for a tiering exception to be granted. Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Emgality 120 milligrams prescribed twice daily for cluster headaches. The Part D Plan denied your request for a tiering exception. We received an expedited 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.Emgality is a brand drug on Tier 4 of the plans formulary. The enrollee was being treated for cluster headaches. However, 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. There are no lower tiered brand drugs of the same type to treat the enrollee's condition.A physician reviewed your appeal and determined that the plan is not required to cover Emgality.
Appeal type: Prescription Drug
Decision: Favorable

You requested Gralise ER, 600 milligram tablets prescribed for post-herpetic neuralgia. The Part D plan denied your request because the national drug code number submitted for this drug indicated that it was not an FDA-approved 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. Your medical records show your doctor prescribed Gralise ER, to treat your post-herpetic neuralgia. Your physician has noted that you have tried and had adverse reactions to all formulary medications for your condition.While the denial reason states that the national drug code number submitted for this drug indicated that it was not an FDA-approved drug, Gralise ER is an FDA-approved drug for the treatment of post-herpetic neuralgia. Furthermore, the Medicare approved compendia support the use of this drug for your condition.A physician reviewed your appeal and determined that the plan is required to cover the Gralise ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armour Thyroid 120 milligram tablet prescribed daily for hyperthyroidism. The Part D plan denied your request because there was no alternate brand name drug for your 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. We determined that the plan is not required to cover the Armour Thyroid. According to Microdex, Armour Thyroid has not been found by the Food and Drug Administration to be safe and effective; and the drug product label has not been approved. Therefore, the drug is excluded from coverage under Medicare Part D. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 420 milligrams/3.5 milliliter cartridge prescribed for mixed hyperlipidemia. The Part D plan denied your request because the documentation did not support 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. Your physician submitted a supporting statement and medical records. The medical records show the physician had prescribed Repatha to treat your mixed hyperlipidemia. Medicare approved compendia 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. A physician reviewed your appeal and determined that the plan is not required to cover Repatha. You have not tried all other alternatives listed within your plans formulary to treat your condition.
Appeal type: Prescription Drug
Decision: Favorable

You requested Horizant 600 milligram tablets prescribed daily for restless leg syndrome. The Part D plan denied your request because the prior authorization criteria were not met. Specifically, the documentation did not specify if the enrollee had tried and failed Ropinirole and Pramipexole. 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 Horizant to treat restless leg syndrome. The Medicare approved compendium does support the use of this drug for this condition. The prescriber states that the enrollee has tried and failed Ropinirole and Pramipexole (Requip and Mirapex), as well as other drugs to treat this condition. Prior authorization criteria were not met but a prior authorization exception is granted. We determined that prior authorization can be given and the plan is required to cover the Horizant.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested the Hepatitis B vaccine Engerix 20 micrograms/milliliter injection. 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 auto-forwarded reconsideration request from the enrollee.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 Engerix as a prophylaxis for Hepatitis B. Your diagnosis of ulcerative colitis and future regimen of receiving Entivio makes you a high risk of contracting Hepatitis B. According to your Evidence of Coverage for your health plan, immunizations are covered by Medicare Part B if the criteria has been met.A physician reviewed your appeal and determined that the Engerix is eligible for coverage under Medicare Part B. Therefore, the drug cannot be considered for payment under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ezetimibe 10 milligram tablets to treat dyslipidemia. You requested that the plan provide a tiering exception. The plan did not make a decision within the required timeframe. 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.Ezetimibe is a generic drug on Tier 3 of the plans formulary. There are no generic 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 the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyanocobalamin 1000 micrograms/milliliter for the enrollees condition. The Part D plan denied your request because vitamins and minerals do not meet the definition of Part D 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. 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 Cyanocobalamin because it is a prescription vitamin and mineral product. Drugs prescribed as 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

You requested Folic Acid 5% (5 milligrams/milliliter) for the enrollees condition. The Part D plan denied your request because vita,ins and minerals do not meet the definition of Part D 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. 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 Folic Acid because it is a prescription vitamin and 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 Corlanor 7.5 tablets prescribed twice a day for postural tachycardia syndrome. The Part D plan denied coverage because the diagnosis given is not a medically accepted indication.  The plan also 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.The prescriber states that the enrollee has hyper-adrenergic postural tachycardia syndrome. The Medicare approved compendia do not support the use of this drug for this condition. Medicare requires the drug be used for a medically accepted indication. Drugs used for conditions that are not medically accepted per CMS compendia are not covered under Part D.A physician reviewed your appeal and determined that the plan is not required to cover Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Forteo 600 mcg/2.4 ml, 20 mcg one time daily, prescribed for periprosthetic osteolysis. 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Forteo to treat your periprosthetic osteolysis. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Forteo. The drug was not prescribed for a medically accepted indication. 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 Testosterone 1.62% gel pump prescribed as four pumps daily for hypogonadism. The Part D plan denied your request because the plans prior authorization criteria 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.Your medical records show your doctor prescribed Testosterone to treat your hypogonadism. The physicians letter stated that your testosterone and follicle stimulating hormone normalized and your symptoms were resolved. Medical records were requested to support that your symptoms improved compared to baseline and that you tolerated treatment. However, the requested records were not provided. The plan requires medical records to show effectiveness of the drug and that prior authorization criteria were met. Therefore, the records do not support that prior authorization criteria were met for Testosterone.   A physician reviewed your appeal based on the available documentation and has determined that the plan is not required to cover Testosterone. The physician reviewer has determined that prior authorization criteria were not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo, 600 micrograms per 2.4 milliliter pen, prescribed for osteoporosis. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization requirements be met 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. We also researched Medicare systems and reviewed the enrollment data available.A physician reviewed your appeal and determined that the plan is not required to cover the Forteo. The medical records show that Forteo was prescribed to treat the enrollees osteoporosis. The Medicare approved compendia do support the use of this drug for osteoporosis. However, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria. The plan allows a total of 24 months of therapy with parathyroid hormone analogs, such as Forteo, for a lifetime. Medicare records show that 26 months of claims have been paid for Forteo for this enrollee. Therefore, the enrollee has exceeded the maximum dose of 24 months of therapy in a lifetime.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate and Ipratropium Bromide 3 milligram nebulizer solution prescribed for acute respiratory distress. 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 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. We determined that the drug is not eligible for Part B coverage. In this instance, drugs used with a nebulizer in a skilled nursing facility or as an inpatient in the hospital are covered under Part D. The documentation submitted does not indicate that you were in a skilled nursing facility or hospital. Therefore, the drug cannot be considered for payment under the Part D benefit.You may wish to submit a request for Albuterol Sulfate and Ipratropium Bromide 3 milligram nebulizer solution to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrochlorothiazide 25 milligrams. The Part D plan denied your request because the drug was not purchased in the United States. We received an auto-forwarded reconsideration request from the plan. 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. The record shows you purchased Hydrochlorothiazide 25 milligrams while outside of the country.We determined that the plan is not required to cover Hydrochlorothiazide  because it was purchased in Naples, Italy. Drugs purchased outside of the United States are excluded from coverage. This decision does not address the medical necessity of the requested drug. It only show that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Metoprolol Succinate 100 milligrams. The Part D plan denied your request because the drug was not purchased in the United States. We received an auto-forwarded reconsideration request from the plan. 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. The record shows you purchased Metoprolol Succinate 100 milligrams while outside of the country.We determined that the plan is not required to cover Metoprolol Succinate because it was purchased in Naples, Italy. Drugs purchased outside of the United States are excluded from coverage. This decision does not address the medical necessity of the requested drug. It only show that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Levothyroxine 25 micrograms. The Part D plan denied your request because the drug was not purchased in the United States. We received an auto-forwarded reconsideration request from the plan. 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. The record shows you purchased Levothyroxine 25 micrograms while outside of the countryWe determined that the plan is not required to cover Levothyroxine because it was purchased in Naples, Italy. Drugs purchased outside of the United States are excluded from coverage. This decision does not address the medical necessity of the requested drug. It only show that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Progesterone 200 milligram capsule prescribed daily. The Part D plan denied your request to cover this drug at a lower tier cost. The plan indicated this is a 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 Progesterone was prescribed; however, Progesterone 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 Progesterone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80 milligrams prescribed as directed for psoriasis. The Part D plan denied your request because the drug you requested is not included on your plans formulary. 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 that your doctor prescribed Taltz to treat your psoriasis. The Medicare approved compendium supports the use of this drug to treat your condition. However, your medical records do not 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 the Taltz.