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

You requested coverage for Solifenacin Succinate, 5 milligram tablets. The Part D plan denied your request because the medication was not included on the plans formulary and the documentation did not support an off-formulary 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. The documentation supports that Solifenacin Succinate has been prescribed to treat the enrollees urge incontinence. However, the prescriber has not indicated why all alternatives required by the plan to treat this condition 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 Tacrolimus 0.5 milligram capsule prescribed once a day for T-cell large granular lymphocytic leukemia. 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 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 Tacrolimus to treat your condition. However, the Medicare approved compendia does 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 Tacrolimus. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy ellipta 200-62.5 blister pack with inhalation device prescribed as directed for chronic obstructive pulmonary disease. 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 to treat your condition. 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.Trelegy ellipta 200-62.5 blister pack with inhalation device 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 to treat your 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 Taltz 80 milligram/milliliter autoinjector prescribed as directed to treat plaque psoriasis. 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 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 Tetracycline Hydrochloride 250 milligrams prescribed for rosacea. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. 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 Medicare approved compendia does 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 Tetracycline Hydrochloride. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tymlos solution pen-injector 80 micrograms to treat age-related osteoporosis without current pathological fracture. 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. 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Tymlos. A physician reviewed your appeal and determined that the plan is not required to cover Tymlos because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Freestyle libre 14 day sensor prescribed for unknown diagnosis. A request for reimbursement was submitted to the plan. We received an auto-forwarded request from the plan to reconsider the appeal. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We determined that the Part D 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Silodosin 8 milligrams prescribed as directed to treat benign prostatic hyperplasia. 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 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 record shows that your doctor prescribed Silodosin to treat your condition. 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 Silodosin because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nubeqa 300 milligram oral tablets prescribed daily for metastatic malignant neoplasm of the prostate. The Part D plan denied your request because 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 medical records show Nubeqa was prescribed to treat metastatic prostate adenocarcinoma or primary malignant neoplasm of the prostate, metastatic. However, the Medicare approved compendia do not support the use of this drug for this condition. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, 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 a tiering exception request for Oxycodone-Acetaminophen 10-325 milligram tablets to treat pain associated with arthritis and lumbosacral spondylosis. The plan did not make a decision within the required timeframe. We received an auto-forwarded reconsideration request from the plan.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.Oxycodone-Acetaminophen 10-325 milligram tablet is a generic drug on Tier 4 of the plans formulary. The plan requested additional information from the prescriber regarding your condition. The prescriber has not submitted a statement to indicate that you have tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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 Myrbetriq 25 milligram extended release 24 hour oral tablets prescribed daily for bladder incontinence. 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.Myrbetriq 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 a tiering exception. There are no lower tiered brand drugs of the same type to treat the enrollee's condition.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil 20 milligram tablets prescribed daily for erectile dysfunction. The Part D plan denied your request because drugs being used for the treatment of erectile dysfunction are excluded from coverage by Medicare Part D. 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 determined that the plan is not required to cover Sildenafil. 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

At issue is Cholestyramine 4 gram powder prescribed as directed. 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.Cholestyramine is a generic drug on Tier 3 of the plans formulary. There are no other drugs of the same type on the lower cost sharing tiers to treat the enrollee's condition. 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 Dextroamphetamine sulfate ER 15 milligram capsules prescribed as directed for autonomic instability with severe fatigue, orthostatic dizziness, postural hypotension, and syncope. 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 medical records show the doctor prescribed Dextroamphetamine sulfate ER for autonomic instability with severe fatigue, orthostatic dizziness, postural hypotension, and syncope. However, 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 Dextroamphetamine sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gammagard (Immune Globulin) Solution prescribed for idiopathic progressive neuropathy. The Part D plan denied your request because the diagnosis provided does not meet the requirements of a Food and Drug Administration medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Gammagard to treat your idiopathic progressive neuropathy. However, the Medicare approved compendium does 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 Gammagard because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 200 milligram tablets prescribed daily for small intestinal bacterial overgrowth, post-surgical malabsorption, and abdominal bloating. The Part D plan denied your request because the provided diagnoses do 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 Xifaxan to treat your small intestinal bacterial overgrowth, post-surgical malabsorption, and abdominal bloating. 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 Xifaxan because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Asmanex inhaler prescribed for asthma.  The Part D plan denied your request for a tiering exception for this covered drug at a lower cost tier. We received this case as auto-forwarded. 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.Asmanex is a brand drug on Tier 3 of the plans formulary. There are no other drugs of the same type on the lower cost sharing tiers to treat the enrollees condition(s). 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 Jardiance 10 milligram tablets prescribed daily for uncontrolled type II diabetes mellitus. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Jardiance 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 cover Jardiance because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Morphine Sulfate 15 milligrams. We received an expedited auto-forwarded reconsideration request from the coverage level. 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 does not contain medical records or a supporting statement to support the prescribed diagnosis. A request for a prescriber statement and medical records was submitted. No records were received. Therefore, it cannot be determined the drug at issue was prescribed for a medically-accepted indication. 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 Acthib vaccine with Diluent. The Part D plan denied the request for reimbursement. 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.The record shows you received the vaccine at your physicians office. Payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or provider's office. You submitted documentation to the plan that includes a copy of an itemized bill. However, the record does not include proof of payment such as an itemized statement showing the bill was paid in full. We determined that the plan is not required to reimburse you for the vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Menactra vaccine. The Part D plan denied the request for reimbursement. 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.The record shows you received the vaccine at your physicians office. Payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or provider's office. You submitted documentation to the plan that includes a copy of an itemized bill. However, the record does not include proof of payment such as an itemized statement showing the bill was paid in full. We determined that the plan is not required to reimburse you for the vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Neopolydex 0.1% suspension. The enrollee is requesting reimbursement for the amount of copay requested at the time of purchase. We received an auto-forwarded request from the plan to reconsider the appeal.We conducted an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows the enrollee purchased Neopolydex from a preferred retail pharmacy for an amount that is less than or equal to the required copayment amount. The amount of the copayment was based on the drug's tier and place of purchase. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We have determined that reimbursement for the copay amount cannot be allowed for the Neopolydex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Yuvafem 10 microgram tablets. The enrollee is requesting reimbursement for the amount of copay requested at the time of purchase. We received an auto-forwarded request from the plan to reconsider the appeal.We conducted an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows the enrollee purchased Yuvafem from a preferred retail pharmacy for an amount that is less than or equal to the required copayment amount. The amount of the copayment was based on the drug's tier and place of purchase. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We have determined that reimbursement for the copay amount cannot be allowed for the Yuvafem.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Procrit 10000 units/milliliter injection prescribed once a week for anemia of chronic disease. 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 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 records submitted at the reconsideration level.Your medical records show your doctor prescribed Procrit to treat your condition. However, the Medicare approved compendia do not support the use of this drug for your condition. 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 Procrit.