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

You requested Saphris 10 milligram sublingual tablet prescribed for schizophrenia. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. We received the documentation and included it in our review.The documentation shows Saphris was prescribed to treat schizophrenia. However In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the prescriber statement and medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Saphris.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Emgality 120 milligram per milliliter prefilled subcutaneous injection syringe prescribed for chronic migraine headaches. The Part D plan denied the request for coverage stating that the medication was not being used for a medically accepted indication.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber has clarified that Emgality has been prescribed for the treatment of chronic migraine headaches, which is a medically accepted indication for the drug as outlined in the Medicare approved compendia. However, the plan has prior authorization requirements that must be met before coverage of this medication will be approved. 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 Eliquis 5 milligram tablets. The Part D plan denied the appeal request for a tiering exception.The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Eliquis 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 the 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 a request for coverage of Metolazone 5 milligram tablets prescribed for the treatment of edema associated with congestive heart failure. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read 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. Metolazone is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the noted 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

At issue is prescribed Diazepam 2 milligram tablets prescribed for anxiety. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested. The documentation shows Diazepam was prescribed to treat anxiety. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Diazepam. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Valtrex 1 gram caplets prescribed to treat an unknown diagnosis. The Part D plan denied the appeal request. The QIC received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation (e.g., the diagnosis related to the requested drug, a prescribers statement, and prior authorization requirements) to show why this medication was needed. We did not receive the requested documentation.The appeal request is for Valtrex 1 gram caplets. However, no medical records have been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia. A physician reviewed the appeal and determined that the plan is not required to cover Valtrex 1 gram caplets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuedexta 20-10 milligram capsules prescribed to treat chanting. The plan denied the request. The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why this medication is needed. We did not receive the requested documentation.The appeal request is for Nuedexta 20-10 milligram capsules prescribed to treat repetitive chanting. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Nuedexta 20-10 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ongentys 50-milligram capsule to treat Parkinsons disease. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The records show your physician prescribed Ongentys to treat your Parkinsons disease. We asked the prescriber to send us medical records of prior drugs tried and failed and why the alternative drugs on your plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. However, we did not receive the documentation.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not medically necessary. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch for chronic low back pain. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The documentation shows Lidocaine 5% patch was prescribed to treat chronic low back pain. 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligram tablet prescribed for plaque psoriasis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. We received the documentation and included it in our review. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the prescriber statement and medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq extended-release 50 milligram tablets. The Part D plan denied the appeal request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Myrbetriq is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Xiidra 5% eye drops prescribed for keratoconjunctivitis sicca. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We requested additional information from the prescribing physician. Specifically, we asked for medical records and a supporting statement to support all formulary alternatives were tried and were ineffective. However, we did not receive the requested documentation.The documentation on hand did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Xiidra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Jadenu 360 milligram tablets prescribed for hemosiderosis due to repeated red blood cell transfusions. The Part D plan denied coverage.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. We requested additional information from the prescribing physician. Specifically, we asked for medical records and a supporting statement to support the enrollee satisfies the plans prior authorization coverage criteria. However, we did not receive the requested documentation.The documentation on hand does not indicate that the enrollee satisfies the plan's prior authorization 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 Ozempic 1 milligram/0.75 milliliter pen injection prescribed for morbid obesity. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Ozempic because it was prescribed for weight loss. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Altace 5 milligram capsule prescribed for hypertension. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Altace 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

At issue is Methscopolamine Bromide 2.5 milligram tablet prescribed for laryngopharyngeal reflux and excessive phlegm. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows Methscopolamine Bromide was prescribed to treat laryngopharyngeal reflux and excessive phlegm. 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 Methscopolamine Bromide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Toprol XL tablet ER 24 hour 50 milligram.  The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Toprol 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

At issue is Tadalafil 5 milligram tablets prescribed for erectile dysfunction and nocturia. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Tadalafil because it was prescribed to treat erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Crestor 10 milligram tablets prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Crestor 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 100 milligram tablets prescribed daily for excessive daytime sleepiness due to jet lag from overseas travel. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered Modafinil for excessive daytime sleepiness due to jet lag from overseas travel. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Vraylar 1.5 milligram tablet to treat bipolar disorder, current episode depressed, mild or moderate severity, unspecified. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan requires for coverage of Vraylar that the enrollee have prior therapy, intolerance or contraindication to at least two of the following: risperidone, olanzapine, quetiapine, ziprasidone or aripiprazole. The documentation includes clinical notes which satisfied the plan's coverage criteria. A physician reviewed the appeal and determined that Vraylar is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Loteprednol Etabonate 0.5% ophthalmic suspension prescribed for the treatment of dry eye syndrome. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read 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 the prescriber to provide a diagnosis, to address the nono-formulary criteria, and to provide supporting medical records.  A reply from the prescriber was not received. Loteprednol Etabonate 0.5% ophthalmic suspension is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all the formulary alternatives included in the plan to treat the noted 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

At issue is Remicade 100-milligram Reconstituted Solution to treat ulcerative colitis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the prescriber ordered Remicade to treat your condition. We asked the prescriber to send us documentation of why the plans alternative drugs are not medically appropriate for you. However, we did not receive the documentation.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not medically necessary. 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 Linzess 290 microgram capsule. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Linzess 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

At issue is a formulary exception request for Vyvanse 60 milligram capsules prescribed for attention deficit hyperactivity disorder. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We requested additional information from the prescribing physician. Specifically, we asked for medical records and a supporting statement to support all formulary alternatives were tried and were ineffective. However, we did not receive the requested documentation.The documentation on hand did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Vyvanse.