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

You requested Cyclosporine modified 100 milligram capsule to prevent rejection in a heart transplant enrollee. The Part D plan denied your request because the enrollee was eligible for Medicare Part B coverage at the time of transplant. 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 the enrollee received a heart transplant on September 28, 2018, which was covered under Medicare Part A. Medicare rules state that drugs used to prevent transplant rejection are covered under Medicare Part B. Therefore, Cyclosporine is eligible under Medicare Part B. We determined the Part D plan is not required to cover Cyclosporine. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclosporine modified 25 milligram capsule to prevent rejection in a heart transplant enrollee. The Part D plan denied your request because the enrollee was eligible for Medicare Part B coverage at the time of transplant. 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 the enrollee received a heart transplant on September 28, 2018, which was covered under Medicare Part A. Medicare rules state that drugs used to prevent transplant rejection are covered under Medicare Part B. Therefore, Cyclosporine is eligible under Medicare Part B. We determined the Part D plan is not required to cover Cyclosporine. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligrams/milliliter prefilled syringe for subcutaneous injection prescribed as directed. You requested that the plan provide a tiering exception for this drug. 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 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. Repatha is a biologic drug on Tier 4 of the plans formulary. There are no biologic 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 Ajovy 225 milligrams/1.5 milliliter subcutaneous injection prescribed for migraine prophylaxis. 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. The prescriber statement indicates the enrollee has not tried some of the other drugs on the plans formulary. The documentation does not show why the enrollee cannot take other drugs on the plans formulary for the condition. A physician reviewed your appeal and determined that the plan is not required to cover Ajovy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Balsalazide disodium 750 milligram capsules prescribed as directed for ulcerative colitis. The Part D plan denied your request for a tiering exception. 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. Balsalazide disodium is a generic drug on Tier 4 of the plans formulary. The doctor submitted a supporting statement. The statement said you could not tolerate sulfasalazine due to an allergy. However, documentation submitted does not support that all generic drugs on lower tiers cannot be used to treat this enrollee. 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 coverage for Temazepam 30 milligrams prescribed daily for trigeminal neuralgia. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Temazepam for trigeminal neuralgia. In review of the Medicare approved compendia, trigeminal neuralgia is not a medically accepted indication for Temazepam. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Temazepam at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spriva Respimat 2.5 microgram inhaler. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. 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 physician submitted a supporting statement. The documentation in the case file does not identify the condition for which the enrollee has been prescribed Spiriva Respimat. The documentation submitted does not support that the enrollee has tried and failed, or is unable to safely try, all alternative drugs on the formulary.A physician reviewed your appeal and determined that the plan is not required to cover Spriva Respimat.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ztlido 1.8 percent patch to treat osteoarthritis of both knees.   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 Lidocaine 5% ointment prescribed for ischemic neuropathy of the left foot. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Lidocaine ointment for ischemic neuropathy of the left foot. 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 Potassium Citrate ER 10 milliequivalent tablets prescribed for a personal history of urinary calculi. You asked the Part D plan to provide 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. We also researched Medicare systems and reviewed the enrollment data available.The records show Potassium Citrate ER is being prescribed for a personal history of urinary calculi. The Medicare approved compendia supports the use of the requested drug for your condition. Potassium Citrate ER is a generic drug that is on your plan's formulary at a Tier 4. The plan formulary includes other drugs on lower tiers that could be used to treat your condition. Your medical records do not show all alternative drugs on the plan formulary have been tried or why you cannot take them. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit. Therefore, the plan is not required to grant a tiering exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac 1% gel prescribed for cervicalgia and dorsalgia. The Part D plan denied your request because the medication is 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 records show you prescribed Diclofenac gel to treat the enrollees cervicalgia and dorsalgia. 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 Diclofenac gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Praluent 75 milligram auto injector prescribed for the enrollees ST elevation myocardial infarction of inferior wall. 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. A request for a prescriber statement to address prior authorization criteria was sent to the prescriber. The requested documentation was not received.The documentation supports the drug was prescribed for the enrollees diagnosis of ST elevation myocardial infarction of inferior wall. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac 1% gel prescribed for pain in the right leg secondary to varicose veins. The Part D plan denied your request because the medication is 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 records show you prescribed Diclofenac gel to treat the enrollees pain in the right leg secondary to varicose veins. 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 reimburse Diclofenac gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligrams tablets to treat erectile dysfunction due to arterial insufficiency. This case was auto-forwarded. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, 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 Calitriol .5 microgram capsules prescribed for chronic kidney disease. The Part D plan denied the request because the drug is end stage renal disease related and not covered under Medicare Part D. 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. According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. Drugs which are eligible for Part B coverage are excluded from Part D coverage. We determined that the plan is not required to cover the Calitriol. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benzphetamine Hydrochloride 50 milligram tablets to treat post-polio syndrome and obesity. 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. Benzphetamine Hydrocholoride has labeling from the Food and Drug Administration for the short term treatment of obesity.  Medicare compendia do not support any other indications for the use of this drug. Drugs prescribed to treat weight gain (promote weight loss) 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 Tadalafil 5 milligram tablets to treat benign prostatic hyperplasia. 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 requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexlizet 180-10 milligram tablet 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. The records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Nexlizet 180-10 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sodium thiosulfate solution 25% quantity 600/14 days. The Part D plan denied your request because the drug was excluded from coverage under Medicare Part D because its manufacturer has not signed the Medicare Coverage Gap Discount Agreement. 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 determined that the plan is not required to cover the Sodium thiosulfate solution. Medicare does not allow Part D drug plans to cover drugs produced by a manufacturer that does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. Records show that the manufacturer, Hope Pharmaceuticals, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, the Part D plan is not required to cover the Sodium thiosulfate solution. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mavyret 100-40 milligram oral tablet prescribed daily for hepatitis C. 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 Mavyret was prescribed to treat chronic viral hepatitis C. However, the accepted use of this drug for this condition requires the enrollee be tested for the presence of HBV by screening for the surface antigen of hepatitis B virus (HBsAg) and anti-hepatitis B core total antibodies (anti-HBc) prior to initiation of therapy. The record does not support this criteria was met. Therefore, 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 Mavyret.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xtampza (Oxycodone) Extended Release 36 milligrams prescribed twice daily for antiplatelet therapy. 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. Your medical records show your doctor prescribed Xtampza for chronic pain. A Medicare approved compendium supports the use of the requested drug for your condition. Xtampza 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 Xtampza 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 Ventolin HFA 90 microgram inhaler prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. 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.Ventolin HFA is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Naratriptan 2.5 milligram tablets prescribed for migraine headaches. The Part D plan denied your request for a quantity limit exception 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. The documentation indicates Naratriptan was prescribed for migraine headaches. The Medicare-approved compendia indicate the maximum dosage for the drug is 5 milligrams/24 hours. The compendia further state The safety of treating more than four headaches in a 30-day period has not been established. You are requesting a quantity greater than has been clinically supported for your condition. An exception to the quantity limit criteria was not met.Therefore, the plan is not required to cover Naratriptan for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo (Pitavastatin) 4 milligrams prescribed daily for hyperlipidemia. 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 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 Livalo for your major depressive disorder. A Medicare approved compendium supports the use of the requested drug for your condition. However, Livalo is a brand name drug on Tier 3 of your plan's formulary. There are no brand name drugs of the same type in 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 Livalo because there are no brand name drugs of the same type in the lower cost-sharing tiers.