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

At issue is Doxycycline Hyclate 100 milligram capsules to treat your infection.  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. We also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, 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 a tier exception for Lexapro 20 milligram tablets prescribed daily for anxiety and depression. The Part D plan denied your request for a tiering exception because Lexapro is a brand name Tier 4 drug and the lower cost-sharing tiers only contain generic alternative 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 also researched Medicare systems and reviewed the enrollment data available. The record shows Lexapro is being prescribed for anxiety disorder and mild depression. The  Medicare approved compendium, supports the use of the requested drug for your condition. The plan shows Lexapro is a brand name Tier 4 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doxycycline hyclate 100 milligram tablets prescribed as directed for a chronic infection of a right hip prosthesis. 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. Doxycycline hyclate is a generic drug on Tier 3 of the plans formulary. The doctor submitted a supporting statement indicating the enrollee has been doing well with Doxycycline hyclate since 2010. However, the plans formulary includes other medications, which are the same class as Doxycycline hyclate, on Tier 2. The doctor did not address why the other medications would not work for the enrollee. All generic drugs on lower tiers appropriate for this condition have not been tried, failed, or are 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 Nexlizet 180-10 milligrams one tablet daily to treat indicated diagnosis of mixed hyperlipidemia and acute myocardial infarction, unspecified.   No medical records were submitted. The plan did not render a decision. This was an auto forwarded 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. It cannot be established that the requested drug is being used for a medically accepted indication based on the limited records available for review. It therefore cannot be considered a Part D drug, and is not available for coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nourianz 20 milligram tablet prescribed one tablet daily for Parkinsons disease. The plan denied the appeal because this drug is not listed on your formulary plan and why the formulary preferred drugs have not worked for you. 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 Nourianz for your Parkinsons disease. This drug is not listed in your plans formulary for your condition. Your doctor did not indicate that you tried drugs listed on your plans formulary for your condition and why they did not work or that they caused adverse effects. Therefore, the requested drug cannot receive a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Nourianz because the documentation does not show that you have met the coverage criteria for a formulary exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Nuedexta 20mg-10mg capsule to treat Pseudobulbar affect. 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.Nuedexta 20mg-10mg capsule is a brand drug on Tier 4 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 Hetlioz 20 milligram tablet prescribed one tablet daily for non-24-hour sleep-wake disorder. The plan denied the appeal because the prior authorization requirements for coverage were not met. 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 Hetlioz for your non-24-hour sleep-wake disorder. Your records do not show you have met the prior authorization conditions of coverage.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz because the conditions of coverage have not been met per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% Ointment. The Part D plan denied your request 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 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 request was submitted to your doctor to address prior authorization criteria. Documentation was also requested to support the diagnosis for the drug at issue. No documentation was received.The submitted documentation includes medical records; however, the records do not contain sufficient documentation to indicate the diagnosis for the drug at issue. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Saizen Saizenprep 8.8 milligrams per cartridge prescribed as directed. 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.Saizen is a biologic 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 Saizen.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Prolia 60 milligrams/milliliter  two per 180 days to treat your condition.  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.In the reconsideration request the prescriber changed the request to one syringe (Prolia 60 milligrams/milliliter) per 180 days. The requested quantity is within the plans allowed quantity limit.  Our Physician Reviewer's opinion is that quantity limit criteria are met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a tiering exception request for Zenpep 40,000-126,000-168,000 units to treat pancreatic insufficiency. The Part D plan did not render a coverage determination. We received an auto-forwarded coverage determination 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.Zenpep 40,000-126,000-168,000 units is a brand drug on Tier 4 of the plans formulary.  The prescriber has stated that all lower tiered drugs to treat the condition have been tried and failed or provided reasons why they would likely not be as effective as the requested drug.  This is a continuation of this drug since 2017, tiering exceptions have been granted previously. Therefore, this drug is eligible for a tiering exception. Our physician reviewer's opinion is that tiering exception criteria are met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mycophenolate Mofetil 500 milligram tablets prescribed daily following a kidney transplant. 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. We also researched Medicare systems and reviewed the enrollment data available. Your records show your doctor prescribed Mycophenolate Mofetil to prevent rejection following a kidney transplant. The Medicare approved compendia support the use of this drug for your condition. You underwent a kidney transplant on May 30, 2005. You entered Medicare Part A/B on August 1, 2017. Based on the information provided, the drug is not eligible for Part B coverage. Therefore, the drug is eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Invokana 300 milligrams prescribed once daily for diabetes mellitus. You asked the Part D plan to provide a cost-sharing tiering exception. The plan denied the appeal because there are no brand name drugs of the same type in the lower cost-sharing tiers that treat your condition. 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 records show Invokana is being prescribed for diabetes mellitus. A Medicare approved compendium supports the use of the requested drug for your condition. Invokana is a brand name drug on Tier 3 of your plan's formulary. There are no brand name drugs of the same type on the lower cost-sharing levels. Therefore, the requested drug is not eligible for a cost-sharing tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Invokana because there are no brand name drugs of the same type in the lower cost-sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 100 mg tablet to treat neoplastic malignant related fatigue.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. .A physician reviewed your appeal. 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

At issue is Shingrix 50 micrograms per 0.5 milliliters. The Part D plan auto-forwarded this case.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation submitted indicates that the requested drug is for a third dose. Shingrix is on Tier 3 of the plans formulary, with a maximum quantity limit of 2 vials per lifetime. Medical records have not been submitted for review, and the plan currently allows 2 vials per lifetime. Therefore, the documentation available 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 Shingrix.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Synthroid 125 micrograms to treat the enrollees condition. 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.Synthroid 125 micrograms 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 Actemra Actpen 162 milligrams/0.9 milliliters to treat rheumatoid arthritis. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.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 would likely cause harm or not be as effective as the requested drug. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diltiazem Hydrochloride powder to treat hemorrhoids. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted.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 initially requested Amphetamine-Dextroamphetamine 20 milligram tablet, 30 tablets per 30 days, prescribed for primary hypersomnia. 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 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 prescriber clarified the diagnosis and medical history in the request for reconsideration.  The prescriber changed the diagnosis to hypersomnia associated with narcolepsy.  Medical records were provided which documented the diagnosis of narcolepsy. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria.  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 Dupixent 300 milligram/2 milliliter syringe prescribed for severe persistent asthma. The Part D plan denied your request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. Your physician submitted a supporting statement. The supporting statement did not support all alternative formulary medications to treat your condition were tried and failed. A physician reviewed your appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxycontin Extended Release 20 milligrams prescribed one tablet every 12 hours for chronic pain syndrome. The plan denied the appeal because your prescriber has not submitted evidence that you have tried and failed or have contradiction or intolerance to Xtampza Extended Release. 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 records show your doctor prescribed Oxycontin Extended Release for your chronic pain syndrome. This drug is not listed in your plans formulary for your condition. Your doctor did not indicate that you tried the drug listed on your plans formulary for your condition and why it did not work or that it caused adverse effects. Therefore, the requested drug cannot receive a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Oxycontin Extended Release because the documentation does not show that you have met the coverage criteria for a non-formulary exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acthar 80 units per milliliter intramuscularly to be given two times a week for rheumatoid arthritis. The Part D plan denied the drug because there was no record of a fungal infection or allergy to steroids. The plan requires prior approval before covering some 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level.Acthar is being requested to treat rheumatoid arthritis. The plan requires the patient to have not seen improvement of symptoms despite trying at least one different Food and Drug Administration approved drug for the condition other than corticosteroids and have had a side effect to corticosteroids that is not seen with the use of Acthar before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteriaA physician reviewed your appeal and determined that the plan is not required to cover the Acthar.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolic Acid Delayed Released 180 milligram tablet prescribed four tablets daily for lung transplant rejection prophylaxis. The plan denied the appeal because the use of this drug is not covered for the 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 Mycophenolic Acid Delayed Released for your lung transplant rejection prophylaxis. The Medicare approved compendia have not approved this drug for your diagnosis.A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolic Acid Delayed Released because the documentation does not show that you have a medically accepted indication per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Remicade 100 milligrams, intravenous solution prescribed to treat rheumatoid arthritis The Part D Plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read 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 requested drug is being prescribed to treat the enrollees condition. Based on the information provided, we have determined the requested drug is not eligible for Medicare Part D coverage, but would be covered under Part B.A physician reviewed your appeal and determined that the requested drug is not eligible for Medicare Part D coverage.