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

At issue is Enbrel 50 milligrams prescribed daily for musculoskeletal pains including seronegative rheumatoid arthritis. The Part D plan denied your request for a tier change request because Enbrel is in the specialty tier of your list of covered 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 Enbrel is being prescribed for musculoskeletal pains including seronegative rheumatoid arthritis. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Enbrel is a generic Tier 5 drug. Your plan does not allow you to receive drugs in this tier at a lower cost share.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Belbuca 450 microgram film 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 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.Belbuca is a non-formulary drug. Non-formulary drugs 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 Gralise ER 600 milligram tablets prescribed for thoracic pain in an enrollee with metastatic lung cancer. 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 submitted documentation indicates your doctor prescribed the drug for thoracic pain in an enrollee with lung cancer. The Medicare approved compendia do not support the use of this drug for your condition. 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 Amphetamine-Dextroamphetamine 20 milligram tablet to treat schizoaffective disorder. 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 your condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Linzess 290 microgram capsules to treat constipation. 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.Linzess is a brand drug covered 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 Amphetamine/Dextroamphetamine 20 milligram tablet to treat multiple sclerosis with fatigue. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Free Style Libre 14 Day Sensor for the diagnosis of type 2 diabetes mellitus. The Part D plan denied the request. We received an expedited 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.The device is subject to Part B and is not eligible to be covered under the Medicare Part D prescription drug benefit. We have determined that the plan is not required to cover the Free Style Libre 14 Day Sensor under the Part D prescription drug benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Viibryd 40 milligrams prescribed daily for the enrollees condition. The Part D plan denied your request for a tiering exception because Viibryd 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 plan shows Viibyrd 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

You requested Gammagard intravenous solution prescribed for primary immune deficiency disease. 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 physician prescriber Gammagard for the treatment of primary immune deficiency disease. However, this drug is eligible for coverage under Medicare Part B. Drugs administered by an infusion pump in the home for the treatment of immune deficiency disease are covered by Medicare Part B. Therefore, this drug is not eligible for Medicare Part D coverage.We determined that the plan is not required to cover Gammagard.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligrams/milliliter injector prescribed for hyperlipidemia. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. Your physician indicates you have tried Simvastatin and Atorvastatin. The documentation indicates the physician had prescribed Repatha to treat your hyperlipidemia. The Medicare approved compendia support 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. Your physician did not indicate that all alternatives on the plan's formulary to treat your condition have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 1% gel prescribed for osteoarthritis of left shoulder. 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 submitted documentation indicates your doctor prescribed the drug for osteoarthritis of left shoulder. The Medicare approved compendia do not support the use of this drug for your condition. 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

You requested Amphetamine-dextroamphetamine XR 15 milligram capsules prescribed for hypersomnia, recurrent major depressive disorder, and generalized anxiety disorder. The Part D plan denied your request for a quantity limit exception 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 prescriber statement shows the doctor prescribed Amphetamine-dextroamphetamine to treat hypersomnia related to recurrent major depressive disorder and generalized anxiety disorder. However, the Medicare approved compendia do not support the use of this drug for hypersomnia related to recurrent major depressive disorder and generalized anxiety disorder.A physician reviewed your appeal and determined that the plan is not required to cover Amphetamine-dextroamphetamine.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Firdapse 10 milligram tablets to treat congenital myasthenic syndrome. The Part D plan denied the request for a formulary exception, 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 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 has an Orphan drug designation per the Medicare approved compendia. It is considered a medically accepted indication. This drug has been used by the enrollee for five years with continued improvement in symptoms. The drug is not on the plans formulary. The plan requires trial and failure or intolerance of two formulary alternatives for the condition being treated. These alternatives are Pyridostigmine and Guanidine. Pyridostigmine is currently being used by the enrollee, and Guanidine has no medically accepted indication for the diagnosis of congenital myasthenic syndrome in the Medicare approved compendia. Therefore, a formulary exception request is granted and the requested drug should be covered by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Trelegy Ellipta 200-62.5-25 micrograms/actuation inhaler prescribed as directed for asthma. 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. Trelegy Ellipta 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.A physician reviewed your appeal and determined that the plan is not required to cover Trelegy Ellipta. A tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Prempro 0.625-2.5 milligram tablet to treat vasomotor symptoms of menopause. 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.Prempro 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 Tadalafil 5 milligrams prescribed as directed for erectile dysfunction. The Part D plan denied your request because the requested drug was being used to treat erectile dysfunction. 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.We determined that the plan is not required to cover Tadalafil 5 milligrams because it is being used to treat erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

YYou requested Gabapentin 100 milligrams prescribed one capsule, twice daily. The Part D plan denied your request because your total out-of-pocket cost was applied to your co-insurance, or deductible amount and these amounts are not reimbursable. 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. The record shows you purchased Gabapentin on October 21, 2020. You paid $18.49 at the pharmacy. The plan co-pay for this drug is $3.58. We determined that the plan is not required to reimburse you the requested amount of $14.91 because this amount was applied to your plan deductible.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 20-10 milligram capsules prescribed as directed. The Part D plan denied your request because there was insufficient information to determine if the drug was 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 plan asked your doctor to send information about your condition; the prescriber stated you were not a patient. We called you to obtain the name and number of a prescribing physician. You provided us with the name of the prescriber contacted by the plan. You also stated you do not need this medication currently. We were unable to obtain additional medical records from a prescribing physician.The available documentation does not show why you were prescribed Nuedexta. There is insufficient documentation to determine if the Medicare approved compendia support the use of this drug for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is polyethylene glycol 3350 powder. 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 that are available Over-the-Counter 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 Ondansetron 4 milligram oral disintegrating tablet to treat nausea and vomiting associated with gastroparesis and gastroesophageal reflux disease. 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 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 does 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20 milligram tablets to treat primary pulmonary hypertension.   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/or the coverage criteria are not satisfied by the provided medical records.  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 Myrbetriq 50 milligram tablet to treat overactive bladder. 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.Myrbetriq 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 Tretinoin 0.01% cream prescribed daily for other rosacea. The Part D plan denied your request because 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 medical records show Tretinoin was prescribed to treat rosacea. However, the Medicare approved compendia do not support the use of this drug for your condition. The prescriber statement indicates the enrollee also has acne rosacea. However, the medical records do not support this diagnosis. The drug was not prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Tretinoin 0.01% cream.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydroxychloroquine 200 milligram tablet prescribed as directed for systemic lupus erythromatosus. 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. Hydroxychloroquine 200 milligram tablet is a Generic drug on Tier 3 of the plans formulary. There are no 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 Xeljanz, 5 milligram tablets prescribed for alopecia areata. The Part D plan denied your request because the enrollee did not have a covered condition. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Xeljanz because alopecia areata is not a medically accepted indication to use this drug.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. Therefore the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, the requested drug does not meet the definition of a Medicare Part D drug and is therefore not eligible for coverage under Medicare Part D.