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

At issue is Octagam solution prescribed for other inflammatory polyneuropathies. The Part D plan denied your request for a non-formulary drug. The plan indicated you did not have a medically accepted indication for this drug. 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 Octagam was prescribed to treat inflammatory polyneuropathies. A prescriber statement also indicates for the diagnosis of anesthesia of skin. However, the Medicare approved compendia does not support the use of this specific drug for the enrollees condition(s).A physician reviewed your appeal and determined that the plan is not required to cover Octagam. 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

At issue is Cosopt PF 2% prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue was covered as a formulary exception and was not eligible for a tiering exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Cosopt PF is a non-formulary drug. Non-formulary drugs approved by formulary exception are covered by the plan on Tier 4 and are 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 Donepazil 23 milligrams prescribed daily for unspecified dementia. 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 Donepazil 23 milligrams daily to treat your unspecified dementia. 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 Donepazil 23 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Evoxac 30 milligrams, one capsule four times a day, prescribed for Sjogrens syndrome. The Part D Plan denied the request because Evoxac is not on the plans formulary; therefore, a tiering exception was not allowed. We received your request to reconsider the appeal.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 systems and reviewed the enrollment data available.The records show Evoxac was prescribed for Sjogrens syndrome. A Medicare approved compendium, supports the use of the requested drug for the enrollees condition. However, Evoxac is not on the plans formulary. Therefore, the requested drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover under the Medicare Part D benefit for Evoxac 30 milligrams, because it is not on the plans formulary.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 100 milligram to treat erectile dysfunction. The Part D Plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix 50 micrograms prescribed for shingles vaccination. The Part D plan denied the request for reimbursement. We received a request to reconsider the appeal. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The record shows you received the vaccination at a clinic. The plan submitted documentation that shows coverage was provided to the clinic for the Shingrix vaccination. The plan calculated reimbursement based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network clinic charged you.We determined that the plan is not required to provide additional reimbursement for the Shingrix vaccine. The plan provided coverage and reimbursement in accordance with your plans out-of-network rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol sulfate 2.5 milligrams per 3 millilter vial 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 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 asthma. However, this drug is eligible for coverage under Medicare Part B. Medicare Part B covers this drug for asthma, 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humalog Kwikpen  prescribed to treat the enrollees condition. 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. You submitted a supporting statement. Your supporting statement indicates that the formulary alternatives could not be tried because the enrollee is allergic to insulin aspart. However, there are no medical records submitted to support the statement provided. Therefore, the records do not adequately show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Humalog Kwikpen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500 milligrams to be given four times a day for CREST syndrome. 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 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.Mycophenolate Mofetil is being requested to treat CREST syndrome. 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin ER 1,000 milligrams prescribed daily for diabetes mellitus. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 systems and reviewed the enrollment data available.Your physician submitted a supporting statement and medical records. The medical records show the physician had prescribed Metformin ER 1,000 milligrams to treat your diabetes mellitus. The 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, the physician submitted a prescriber statement that does not indicate you have never tried all alternative drugs to treat your diabetes mellitus. Your medical records do not show all alternative drugs on the plan formulary have been tried or why you cannot take them. Therefore, the plan is not required to grant an off-formulary exception for the Metformin ER 1,000 milligrams.A physician reviewed your appeal and determined that the plan is not required to cover Metformin ER 1,000 milligrams because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levothyroxine 75 micrograms prescribed daily for hypothyroidism. The Part D Plan denied your request for a tiering exception. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The record shows you were prescribed Levothyroxine 75 micrograms daily for hypothyroidism. Levothyroxine is a generic drug on Tier 2 of the Plan's formulary. 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 cover the Levothyroxine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocortisone Acetate 25 mg suppository. 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 plan denied the request for coverage of Hydrocortisone Acetate 25 mg suppository because the enrollees Part D drug plan cannot cover drugs that are part of the Food and Drug Administration's Drug Efficacy Study Implementation program. These drugs are considered to be less than effective per Food and Drug Administration review.A physician reviewed your appeal and determined that the plan is not required to cover Hydrocortisone Acetate because the drug does not meet the definition of a Part D drug per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Loteprednol Etabonate, 0.5% suspension drops prescribed for dry eye syndrome. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Loteprednol Etabonate as an off-formulary drug.The record shows that Loteprednol Etabonate was prescribed to treat dry eye syndrome. The Medicare approved compendia support the use of the requested drug for this condition. However, the submitted documentation does not indicate that the patient has tried and failed all formulary alternatives. Therefore, an off-formulary exception cannot be granted for the Loteprednol Etabonate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Nucynta to treat low back pain. The Part D plan denied the request.  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.Nucynta is a non-formulary drug. Non formulary drugs are not eligible for tiering exceptions. Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is NP Thyroid to treat hypothyroidism. 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 prescriber has not indicated why all alternatives required by the plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clozaril 100 milligrams prescribed daily for bipolar disorder. The Part D plan denied your request because the Food and Drug Administration has not approved this drug for your diagnosis. 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 Clozaril 100 milligrams to treat your bipolar disorder as well as other conditions named by your doctor. However, the Medicare approved compendia does 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 Clozaril. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ursodiol 300 milligrams prescribed three times daily for chronic cholestasis. The Part D plan denied your request for a tiering 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. Ursodiol is a generic drug on Tier 3 and Tier 4 of the plans formulary based on a dosage of 250 milligrams or 500 milligrams. The record shows Ursodiol 300 milligrams was prescribed to treat chronic cholestasis secondary to a previous open cholecystectomy with common bile duct injury. However, Ursodiol at a dosage of 300 milligrams is not on the plans formulary. Medicare has already granted a formulary exception for the drug. However, a tiering exception cannot be allowed for a drug that is not on the plans formulary. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Ursodiol 300 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Voriconazole 200 milligrams prescribed daily for cellulitis. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 record shows you were prescribed Voriconazole for cellulitis.In review of the Medicare approved compendia, cellulitis is not a medically accepted indication for Voriconazole. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the drug at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ibrance 125 milligram (21/28) tablets prescribed for metastatic breast cancer, HER2 positive. 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. Your medical records show your doctor prescribed the requested drug to treat your metastatic breast cancer, HER2 positive. 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 mg 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.Eliquis 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.Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed three times a day for chronic pain syndrome, and low back pain radiating to right lower extremity possibly secondary to lumbar radiculopathy. 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 Cyclobenzaprine Hydrochloride for chronic pain syndrome, and low back pain radiating to right lower extremity possibly secondary to lumbar radiculopathy.In review of the Medicare approved compendia, chronic pain syndrome, and low back pain radiating to right lower extremity possibly secondary to lumbar radiculopathy are not medically accepted indications for Cyclobenzaprine Hydrochloride. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Cyclobenzaprine Hydrochloride at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Botox 200 unit vial prescribed as a prophylaxis for migraine headaches. The Part D plan denied your request for a tiering exception because the drug you requested is not included on the plans formulary. 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.Botox is a brand drug, which is not included on the plans formulary. The plan agreed to cover the drug, but the plan does not provide tiering exceptions for non-formulary drugs approved as formulary exceptions. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Botox.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azathioprine 50 milligram tablets prescribed for statin induced autoimmune necrotizing myositis. 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. Your medical records show your doctor prescribed the requested drug to treat statin induced autoimmune necrotizing myositis. 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 5 milligram tablets prescribed twice daily for anorexia nervosa; weight loss and appetite post transplant. 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. Your medical records show your doctor prescribed the requested drug to treat your anorexia nervosa; weight loss and appetite post transplant. 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Esbriet 267 milligrams prescribed for idiopathic pulmonary fibrosis. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. 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. Esbriet is a brand drug on Tier 5, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the specialty tier from the tiering exception process. Therefore, this drug is not eligible for a tiering exception.