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

At issue is Repatha 140 milligrams per 1 milliliter subcutaneous prescribed two per month for mixed hyperlipidemia. 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.Office notes and a statement have been provided. The prescriber stated that the enrollee did try and was intolerant of Zocor. However, the records do not show why the enrollee cannot take all other drugs on the plans formulary for this condition. Specifically, Praluent was not tried.A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Botox 100 unit injections prescribed as directed for chronic pelvic pain. 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 documentation shows the doctor prescribed Botox to treat chronic pelvic pain related to levator muscle spasm and endometriosis. However, the Medicare approved compendia do not support the use of Botox for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Botox.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nifedipine 10 milligrams prescribed daily to treat autonomic dysreflexia. The Part D plan denied the request because the provided diagnosis is a not 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 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 the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for arthritis. The Part D plan denied your request because the diagnosis is not 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 physician states he prescribed the Lidocaine patch for your arthritis. 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 Lidocaine 5% patch. This medication has not been medically approved for your diagnosis.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lansoprazole 30 milligrams prescribed as directed for gastroesophageal reflux disease. 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 Lansoprazole for gastroesophageal reflux disease. 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 Lansoprazole.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate mofetil 500 milligrams prescribed as directed for retriperitoneal fibrosis. 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 Mycophenolate mofetil 500 milligrams to treat your retriperitoneal fibrosis. 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 Mycophenolate mofetil 500 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Advair Diskus 250/50 micrograms prescribed as directed for asthma. 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. Advair Diskus 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 Baclofen to treat Central Pain syndrome and fibromyalgia.  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 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 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 the enrollees condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D. The tiering exception request is not further considered.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligrams per 2-milliliter syringe prescribed for severe persistent asthma, uncomplicated. 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 Dupixent to treat your severe persistent asthma, uncomplicated. The 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. Specifically, 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.A physician reviewed your appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xhance 93 micrograms per actuation. 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.This drug is being provided by your plan under a formulary exception. It is not on the plans formulary. However, 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. We have determined the plan is not required to provide a tiering exception for Xhance.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 250 milligram capsules prescribed for hereditary and idiopathic neuropathy and chronic inflammatory demyelinating polyneuritis. The Part D plan denied your request because the medication is not prescribed for a medically accepted indication. 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. The records show you prescribed Mycophenolate Mofetil to treat the enrollees neuropathy and polyneuritis. 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 Mycophenolate Mofetil. We cannot consider coverage under Medicare part D for a drug that is not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed topically for rheumatoid arthritis with rheumatoid factor. The Part D plan denied your request because the Food and Drug Administration approved use for this drug is for the relief of pain associated with post-herpetic neuralgia. Coverage is also provided for the treatment of diabetic neuropathic pain and neuropathic pain associated with cancer. You do not have these diagnoses. 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. We also researched Medicare systems and reviewed the enrollment data available.We asked your prescriber to send us medical records. We did not receive any additional information. The record shows that your doctor prescribed a Lidocaine 5% patch for you. You do not have a covered Food and Drug Administration diagnosis for this drug. A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine 5% patch because you do not have a covered diagnosis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tymlos 80 micrograms per dose pen injector for osteoporosis without current pathological fracture. The Part D plan denied your request because this drug is not medically accepted for this condition. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The 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 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 Tymlos.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Octreotide Acetate Solution 1000 micrograms/milliliter prescribed for non-infective diarrhea. The Part D plan denied your request because the criteria were not met. The plan stated that there was no documentation of a high pre-treatment insulin like growth factor based on the laboratory reference, or indication the enrollee had an inadequate or partial response to surgery or radiotherapy or there was a clinical reason for why the patient had not had surgery or radiotherapy. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The prescriber states that the enrollee has non-infective diarrhea which is an acceptable indication for the drug per Medicare approved compendia. The prior authorization requirements were only in reference to a diagnosis of acromegaly which is not the diagnosis in this case. A physician reviewed your appeal and determined that the plan is required to cover Octreotide Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mavyret 100 milligram-40 milligram tablets, 56 tablets per 28 days to treat Chronic Hepatitis C, genotype 1, in a treatment-naive enrollee with compensated cirrhosis.  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.  Namely, the prior authorization requires the drug to be prescribed by or in consultation with, a gastroenterologist, hepatologist, or infectious disease doctor. 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 a tiering exception request for Stilto Respimat Inhalation Mist to treat Chronic Obstructive Pulmonary Disease.   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.Stiolto Respimat Inhalation Mist 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

At issue is Mesalamine 1.2 grams for ulcerative colitis. 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.Mesalamine is a generic drug on Tier 4 of the plans formulary. The prescriber statement shows the drug is ordered for the enrollees ulcerative colitis. There are no generic 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 Xeljanz XR 11 milligrams prescribed as directed for rheumatoid arthritis. 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. 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 Xeljanz XR 11 milligrams to treat your rheumatoid arthritis. 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 Xeljanz XR because your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Belsomra 10 milligrams prescribed daily at bedtime to treat insomnia. The Part D Plan denied the 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 prescriber did not clearly indicate 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. The physician reviewer's opinion is that formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception. At issue is a tiering exception request for Brilinta 90 milligram tablet for the prophylaxis of stroke in an enrollee with stenosis of the carotid artery and a history of myocardial infarction.   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.Brilinta 90 milligram  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 Nexletol 180 milligrams prescribed daily for hyperlipidemia, unspecified. 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 Nexletol 180 milligrams to treat the enrollees hyperlipidemia, unspecified. 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 Nexletol 180 milligrams. We cannot consider prior authorization approval for a drug the Part D plan cannot cover.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5 milligrams prescribed as directed for benign prostatic hyperplasia. The Part D plan denied coverage because medical necessity was not established. 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Tadalafil 5 milligrams as directed for benign prostatic hyperplasia. 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 coverage criteria has been met. 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 Tadalafil.
Appeal type: Prescription Drug
Decision: Favorable

You requested Cyclobenzaprine 10 milligrams prescribed daily for fibromyalgia. The Part D plan denied your request because the prior authorization criteria were 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. The medical records show the doctor prescribed Cyclobenzaprine to treat fibromyalgia. The Medicare approved compendium does support the use of this drug for this condition. The prescribers statement supports that Pregabalin and Duloxetine were tried in the past and failed. The documentation provided shows the prior authorization criteria has been met. Therefore, the drug requested is eligible for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine. The Medicare rules above have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prednisone 5 milligrams prescribed as directed for osteoarthritis. The Part D plan denied the request because it 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 record shows you were prescribed Prednisone 5 milligrams as directed for osteoarthritis. 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 Prednisone because it was not prescribed for a medically accepted indication.