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

You requested Amlopidine 10 milligram tablets prescribed for you while inpatient in the hospital. The Part D plan denied your request for coverage under Medicare Part D because the National Drug Code for Amlopidine was either not provided or for a discontinued drug. We received a reconsideration 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 record shows the hospital submitted Amlopidine with National Drug Code 31722-0239-10 for payment to your plan. We found that National Drug Code 31722-0239-10 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover the Amlopidine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lispro 100 unit/milliliter subcutaneous pen prescribed for you while inpatient in the hospital. The Part D plan denied your request for coverage under Medicare Part D because the National Drug Code for Lispro was either not provided or for a discontinued drug. We received a reconsideration 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 record shows the hospital submitted Lispro with National Drug Code 00002-8799-59 for payment to your plan. We found that National Drug Code 00002-8799-59 is not listed with the Food and Drug Administration as a valid code for this drug because it has been discontinued. Therefore, we determined the plan is not required to cover the Lispro.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyzulta 0.024% eye drops prescribed for the enrollees condition. The Part D plan dismissed your request for a tiering exception because the drug at issue, if covered as a formulary exception, would then not be eligible 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.Vyzulta is a non-formulary brand drug. Non-formulary drugs 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 a lower cost tiering exception for Praluent 75 milligrams per milliliter subcutaneous injection prescribed for pure hypercholesterolemia and peripheral vascular disease. The Part D Plan denied your request because the documentation did not explain why the plans alternative drugs in lower tiers would not work. 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. Praluent is a brand drug on Tier 3 of the plans formulary. The submitted medical records do not sufficiently address why the brand drugs of the same type on the lower tiers of the plans formulary to treat the enrollees condition have been tried and failed, or are contraindicated. Simply stating that the enrollee is stable on their current therapy regimen and cannot make any changes is not adequate. Therefore, the plan is not required to grant a tiering exception for Praluent.A physician reviewed your appeal and determined that Praluent is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine HCL 10 milligram tablets to treat chronic migraines. 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 the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 Diclofenac Sodium Gel 1% prescribed for shoulder pain. The Part D plan denied the request. We received a reconsideration request from the plan. 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 regulations and Medicare approved compendia. Medicare approved compendia does not support the use of this medication for the diagnosis submitted. Therefore, it is ineligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium Gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Proair HFA Inhaler to treat asthma and chronic obstructive pulmonary disease. The Part D plan denied your request for a non-formulary exception. 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 records submitted at the reconsideration level. The prescriber has not indicated why all alternatives which are 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 coverage for Uloric 80 milligram tablets. The Part D plan denied the request stating that the medication was prescribed for a non-medically accepted indication.  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.The documentation indicates that Uloric has been prescribed for the treatment of hyperuricemia without signs of inflammatory arthritis secondary to kidney disease. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. It is noted that the compendia support the use of Uloric for the chronic management of hyperuricemia in patients with gout and that Uloric it is not recommended for treatment of asymptomatic hyperuricemia. Therefore, the requested drug is being used for a non-medically accepted indication and is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the Uloric.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 100 microgram tablets 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 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.Synthroid 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 Rivastigmine 4.6 milligram/24 hour Patch prescribed to treat Alzheimers disease. 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 Rivastigmine Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Glatiramer Acetate 20 milligram/milliliter syringe prescribed to treat multiple sclerosis. 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. This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs 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

At issue is Lidoderm External Patch 5% prescribed to treat severe nerve damage status post mastectomy. 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. A drug may be provided by the plan under a formulary exception. However, per Medicare rules, non-formulary drugs 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

At issue is Humira 40 milligram per 0.4 milliliter prefilled syringe to treat rheumatoid arthritis. The Part D plan denied the request. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read all documentation submitted. This includes any information submitted at the reconsideration level.We asked you to send us a statement and medical records to show why the drug is medically necessary. We received the statement and included it in our review. However, the medical records were not submitted.The documentation does not satisfy the plans coverage criteria. The prescriber has not addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided 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

You requested Dupixent 300 milligram/2 milliliter injection pen. The Part D plan denied your request. We received an 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 include medical records or evidence of a prescribed diagnosis. A request for medical records and a supporting statement to address formulary alternatives was submitted. No documentation was received from your doctor. As it cannot be determined the biologic was 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Memantine H 5 milligram oral tablet prescribed daily for dementia with Lewy boddies. The Part D plan denied your request for a tiering exception because the requested drug is not on the plans formulary. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Memantine Hydrochloride is a generic drug on Tier 3 of the plans formulary. Your doctor submitted a supporting statement. The statement said you tried Exelon with no effect. However, the plans formulary includes Donepezil Hydrochloride, which is the same class as Memantine Hydrochloride, on Tier 2. Your doctor did not address why the Donepezil Hydrochloride would not work for you. All generic drugs on lower tiers have not been tried. 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 Austedo 6 milligrams twice daily. At initial determination and redetermination the diagnosis of drug induced subacute dyskinesia was given. 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.At reconsideration a diagnosis of tardive dyskinesia was given. A request was submitted to the prescriber to provide medical records to support this diagnosis. No medical records were provided by the prescriber to support the diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Juven Powder Pack 7 gram-1.5 gram Packet prescribed to heal a pressure ulcer. The Part D plan denied the request. We received a reconsideration request. 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 regulations and Medicare approved compendia. This drug is excluded from Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Juven Powder Pack.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Emgality Pen Injector 120 milligram/milliliter prescribed to treat migraines. The Part D plan did not provide a timely redetermination decision. 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 records submitted at the reconsideration level. The drug is not on the plans formulary and the prescriber has not submitted documentation of all other alternative medications, on the plans formulary, that have been tried.A physician reviewed your appeal and determined that the plan is not required to cover a formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for thoracic radiculopathy. The Part D plan denied your request because the brand name medication is off-formulary. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. It has been noted that generic substitution is allowed. The generic lidocaine 5% patch is on the plans formulary. However, the records show you prescribed Lidocaine 5% patch to treat the enrollees pain secondary to thoracic radiculopathy. 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 Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydroxyzine pamoate 25 milligram capsules prescribed once daily for insomnia. 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. The record shows the physician prescribed Hydroxyzine pamoate for insomnia. 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 the Hydroxyzine Pamoate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan potassium 100 milligram tablets prescribed as directed. 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. Losartan potassium is a generic drug on Tier 1 of the plans formulary. Tier 1 drugs are not eligible for a tiering exception because they are already classified as the lowest tier on the plans formulary. 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 Budesonide EC 3 milligram capsules. The Part D plan denied the request stating that the medication was prescribed for a non-medically accepted indication.  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.The documentation indicates that Budesonide EC has been prescribed for the treatment of protein losing enteropathy and hepatomegaly as a complication of a Fontan palliation procedure performed due to congenital heart disease with hypoplastic left heart syndrome. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. 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 the Budesonide EC.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sumatriptan Succinate 6 milligram/0.5 milliliter solution for the enrollees condition. The Part D plan denied your request for a tiering exception because the prescriber did not address all alternatives were tried and failed. 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.Sumatriptan Succinate is a generic drug on Tier 4 of the plans formulary. Your doctor submitted a supporting statement. The statement did not address why all alternative lower-tier medication on the plans formulary would not work for you. All generic drugs on lower tiers have not been tried. 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 Spravato 84 milligram tablet prescribed to treat the enrollees condition. The Part D plan denied the request because the drug requested was excluded from Part D coverage. We received an expedited 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 prescriber was asked to send in medical records to support the diagnosis listed and all other alternative medications tried and failed. A response from the prescriber was not received. Therefore, based upon the current record, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amphetamine-Dextroamphetamine ER 30 milligrams prescribed for attention deficit/hyperactivity disorder. The Part D plan denied your request for a tiering exception because the drug at issue was an off formulary drug and was not eligible 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.The documentation includes Amphetamine-Dextroamphetamine as a Tier 2 generic drug on the plans formulary. The physician submitted a supporting statement that Amphetamine-Dextroamphetamine was prescribed to treat attention deficit/hyperactivity disorder. However, the physician did not address why all alternative lower-tier medications on the plans formulary would not work. All generic drugs on lower tiers have not been tried. 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 Humira 40 milligram/ 0.4 milliliter injection pen prescribed as directed to treat cutaneous sarcoidosis. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received an expedited 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.