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

At issue is Atropine Sulfate 1% ophthalmic solution prescribed 2 drops in right eye daily for eye pressure. The Part D plan did not make a decision.We received the case to perform 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 shows the doctor prescribed Atropine Sulfate 1% ophthalmic solution to treat the enrollees right eye pressure. 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 Atropine Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dofetilide 250 microgram capsule to treat atrial fibrillation. The Part D plan denied your request for a tiering exception.We received the case to perform 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.Dofetilide is a generic drug on Tier 4 # of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat your condition have been tried or deemed contraindicated. 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 Restasis 0.05 percent eye emulsion prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception.We received the case to perform 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. Restasis is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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

You requested Nitazoxanide 500 milligram tablets prescribed for acute gastroenteropathy due to Norwalk agent. The Part D plan denied your request. We received the case to perform 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 your doctor prescribed Nitazoxanide to treat your acute gastroenteropathy due to Norwalk agent. 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 Nitazoxanide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pregabalin 100 milligram capsules prescribed for primary generalized osteoarthritis, pain in unspecified joints, and other chronic pain. The Part D plan denied your request. We received the case to perform 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 initially provided the diagnosis of primary generalized osteoarthritis, pain in unspecified joints, and other chronic pain.  In the request for reconsideration, the prescriber changed the diagnosis to fibromyalgia.  There are no medical records submitted to support the change in diagnosis. 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Welchol 625-milligram tablet to treat hyperlipidemia, unspecified. The Part D plan denied the 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nubeqa 300 milligram tablet to treat metastatic castration resistant prostate cancer. The Part D plan denied your request. We received the case to perform 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 your doctor prescribed Nubeqa to treat your metastatic castration resistant prostate cancer. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law.  As such, an exceptions request based on medical necessity cannot be considered because the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Nubeqa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dulera 200/5 microgram/actuation aerosol inhaler prescribed for chronic obstructive pulmonary disease, unspecified. The Part D plan denied your request for a tiering exception.We received the case to perform 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 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.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 Simponi 100-milligrams/milliliter Solution Auto-Inject subcutaneous to treat Crohns disease, unspecified, without complications. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.A physician reviewed the 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 Lantus Solostar 100 units per milliliter subcutaneous injection pen prescribed for type 2 diabetes with kidney complications. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. Lantus is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Lantus at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Sildenafil 50 milligram tablets, 12 tablets per 12 days, prescribed for erectile dysfunction due to type 2 diabetes. The Part D plan approved the request for the Sildenafil under your supplemental drug wrap benefit. However, the plan denied the request for 12 tablets per 12 days, as it exceeded the quantity allowed by the supplemental drug wrap benefit.We received the case to perform 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.Your doctor has prescribed 12 tablets per 12 days of the Sildenafil tablets. However, the supplemental drug wrap benefit limits the quantity of Sildenafil tablets to 6 tablets per 30 days. An exception to the quantity limit criteria has not been met. A physician reviewed the appeal and determined that the plan is not required to cover more than 6 tablets per 30 days.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta Extended Release 100 milligram tablets prescribed to treat low back pain and neuralgia. The Part D plan denied your request.We received the case to perform 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 prescriber indicated that you have had appropriate and helpful pain coverage with less concern for abuse while on Nucynta Extended Release tablets. However, all formulary alternative drugs were not addressed. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Nucynta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Imbruvica 420 milligram tablets prescribed for cold agglutinin hemolytic anemia. The Part D plan denied your request. We received the case to perform 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 Imbruvica to treat cold agglutinin hemolytic anemia. The prescriber states the National Comprehensive Cancer Network guidelines show that Imbruvica is indicated for the treatment of cold agglutinin disease associated with Waldenstroms/lymphoplasmacytic lymphoma. However, the bone marrow test results and laboratory reports submitted for review do not support that this enrollee has an underlying malignancy or hyperviscosity 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 Imbruvica.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Guaiatussin AC oral syrup 10 milligrams per 5 milliliters- 100 milligrams per 5 milliliters for the symptomatic treatment of cough and cold.   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.Drugs prescribed for the symptomatic treatment of cough and colds 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 Guaifenesin 100 milligrams per 5 milliliters for the symptomatic treatment of cough and cold.   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.Drugs prescribed for the symptomatic treatment of cough and colds are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle test strip 150, per 30 days prescribed for the diagnosis of diabetes mellitus type 2. The Part D plan denied your request. We received the case to perform 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 Freestyle test strips because they are not considered a medical supply directly associated with the injection of insulin. Although, this item is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. This decision does not address the medical necessity or appropriateness of the item. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz 5 milligram tablets prescribed twice a day for arthropathic psoriasis. The Part D plan denied your request.We received the case to perform 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 prescriber indicated that you are stable on the current drug and have a high risk of significant adverse clinical outcome with medication change. However, all formulary alternative drugs were not addressed. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rytary Extended Release 61.25 milligram-245 milligram capsules prescribed to treat Parkinsons disease. The Part D plan denied your request for a tiering exception.We received the case to perform 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. Rytary Extended Release capsules 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

You requested Guanfacine Hydrochloride Extended Release 2 milligram tablets prescribed for hypertension. The Part D plan denied your request. We received the case to perform 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 your doctor prescribed Guanfacine Hydrochloride Extended Release to treat your hypertension. However, the Medicare approved compendia do not support the use of this drug, as prescribed, for your condition. A physician reviewed your appeal and determined that the plan is not required to cover hypertension.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tresiba Flextouch 100 unit/milliliter prescribed for diabetes. The Part D plan denied your request for a tiering exception.We received the case to perform 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. Tresiba Flextouch is a brand name drug on Tier 2 of the plans formulary. There are no brand name 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 Forteo Solution Pen-injector 620 microgram/2.48 milliliter prescribed for postmenopausal osteoporosis. The Part D plan denied your request.We received the case to perform 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 Forteo to treat your postmenopausal osteoporosis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation 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 Forteo. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle libre 14 day sensor prescribed for the diagnosis of diabetes mellitus type 2. The Part D plan denied your request. We received the case to perform 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 Freestyle libre 14 day sensor because it is not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. 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 Lantus 100 unit/milliliter vial prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception.We received the case to perform 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.Lantus is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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

You requested reimbursement of Oxycodone-Acetaminophen 10-325 milligram tablets prescribed two daily every 6 hours as needed for pain with a quantity of 168 tablets. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. A request was sent to your prescriber for additional information including the diagnosis and medical records to support the diagnosis and the medical necessity of the drug. There were no medical records submitted. The documentation was insufficient to determine if the amount of drug prescribed is required.  A physician reviewed your appeal and determined that the plan is not required to cover reimbursement of Oxycodone-Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Methylphenidate Hydrochloride 20 milligram tablets. The Part D plan denied the request for coverage  We received the case to perform 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 Methylphenidate Hydrochloride has been prescribed for major depressive disorder and fatigue. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 3% Gel to treat arthralgia, multiple joints. The Part D plan denied the 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.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.