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

At issue is Myrbetriq ER 50 milligram tablets prescribed three times daily. 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. Myrbetriq ER  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 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 Breo Ellipta 100-25 microgram inhaler 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. This drug is 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 Rocklatan ophthalmic solution 0.02-0.005 % prescribed for primary open-angle glaucoma. 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 medical records show Rocklatan was prescribed to treat your primary open-angle glaucoma. 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 medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Rocklatan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prescribed Arestin 1 milligram cartridge for an unknown diagnosis. The Part D plan denied the request because the National Drug Code for Arestin was not provided.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 also researched Medicare systems and reviewed the enrollment data available. The record shows Arestin was used in a therapeutic service as an integral part of a procedure. The National Drug Code for Arestin is included in the records. According to Medicare rules, drugs used as an integral part of a procedure that is a diagnostic or therapeutic service are excluded from coverage under Part D. Therefore, it is excluded from coverage under the Part D benefit. However, Arestin may be covered under Medicare Part B, as a medical benefit. Therefore, we determined that the Part D plan is not required to reimburse you for the Arestin. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.We determined that the plan is not required to cover Arestin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil Citrate 20 milligram tablets prescribed for pulmonary hypertension due to lung diseases and hypoxia. 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 documentation shows your doctor prescribed Sildenafil Citrate 20 milligram tablets to treat your pulmonary hypertension due to lung diseases and hypoxia. The medical records provided document the diagnoses of chronic obstructive pulmonary disease, obstructive sleep apnea, and congestive heart failure. The use of the requested drug to treat the provided diagnoses 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.A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix 50 microgram/0.5 milliliter suspension prescribed for shingles vaccination. 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 plan submitted documentation that shows you were still in the deductible stage of the Part D benefit when you received the Shingrix vaccination. Your plans Evidence of Coverage states that you are responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined that this drug was paid correctly and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 5 milligram oral tablet. 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.Farxiga is a brand drug on Tier 2 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 Travoprost 0.04% drops prescribed daily for open angle glaucoma. 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. 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. However, we did not receive the documentation.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 medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Travoprost.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Januvia 100 milligram tablet. 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. Januvia is a brand drug on Tier 2 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 Lidocaine 5 percent topical patch prescribed as directed for left shoulder pain and post rotator cuff repair. 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 documentation shows your doctor prescribed Lidocaine 5 percent topical patch to treat your left shoulder pain and post rotator cuff repair. However, the Medicare approved compendia do 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 Lidocaine 5 percent topical patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tirosint 112 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. This drug is 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 50 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. Myrbetriq ER 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 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 tiering exception for Trospium Chloride ER 60 milligram extended release capsules prescribed for urinary incontinence. 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. During this review, a request was sent to your doctor to address the tiering exception request and to provide supporting medical records. However, your doctor did not respond to the request.Trospium Chloride ER is a generic drug on Tier 3 of the plans formulary. Your doctor has not addressed why all of the generic drugs of the same type to treat your condition on the lower tiers of the plans formulary have been tried and failed, or are contraindicated. A physician reviewed your appeal and determined that the tiering exception requirements have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar (Cariprazine) 3 milligram oral 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.Vraylar 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 your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

You requested Lotemax 0.5% ophthalmic gel prescribed for dry eyes. 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. Your medical records show your doctor prescribed Lotemax to treat your dry eyes. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Loteprednol etabonate 0.25% ophthalmic suspension is indicated for the short-term (up to 2 weeks) treatment of the signs and symptoms of dry eye disease.A physician reviewed your appeal and determined that the plan is required to cover Lotemax. You have a covered condition for use of Lotemax and the drug is on your formulary.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Afinitor 10 milligram tablets prescribed as directed for PIK3CA mutation positive ovarian cancer that is estrogen receptor/progesterone receptor negative. 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 documentation shows Afinitor was prescribed to treat the enrollees PIK3CA mutation positive ovarian cancer that is estrogen receptor/progesterone receptor negative. However, the Medicare approved compendia do not support the use of this drug for this condition. The Food and Drug Administration states Everolimus is not indicated for ovarian cancer or for PIK3CA mutated ovarian cancer. The physician gave two citations to support use. However, neither can be accepted.  The first is from the journal called Oxidative Medicine and Cellular Longevity, which is not a Medicare approved journal. The second article is from Gynecologic Oncology, which is a Medicare approved journal called Phase 2 trial of Everolimus plus Letrozole in relapsed ER positive High Grade Ovarian Cancer. However, this article is not applicable to patient as it is studying patients who cancer is estrogen receptor positive and Everolimus is being given with Letrozole. The enrollee has estrogen receptor/progesterone receptor negative cancer.A physician reviewed the appeal and determined that the plan is not required to cover Afinitor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Captopril 50 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. Captopril is a generic drug on Tier 3 of the plans formulary. Your doctor indicated you tried and failed Hydrochlorothiazide, Lisinopril, Losartan, Olmesartan, Telmisartan, Inesartan, Valsartan, Amlodipine and Atenol. However, your doctor did not submit medical records and also did not address why all the drugs available on the lower tiers of your plans formulary would not work for you. 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 Otezla 30 milligram tablets prescribed as directed for rheumatoid arthritis. 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 documentation shows your doctor prescribed Otezla to treat your rheumatoid arthritis. However, the Medicare approved compendia do 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 Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram capsules prescribed as directed for anorexia related to end stage lung cancer. 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 documentation shows your doctor prescribed Dronabinol to treat your anorexia related to end stage lung cancer. However, the Medicare approved compendia do 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Otezla 10, 20, and 30 milligram tablet pack. 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. At initial determination the diagnosis of congenital cutaneous mastocytosis was given. At redetermination the physician submitted a supporting statement and medical records that show Otezla was prescribed to treat Hailey-Hailey disease also known as familial benign pemphigus. 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, as ordered, is not being used for a medically accepted indication. 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 Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Invokana 100 milligram tablets prescribed for type 2 diabetes mellitus. 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 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.Invokana is not included in the plans formulary. During this review, a request was sent to the prescriber to address why the medications that are included in the formulary 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. However, the prescriber did not respond to the request. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% Gel Pump. At initial determination and redetermination the diagnosis of testicular hypofunction was given. 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.At reconsideration, medical records were submitted supporting the diagnoses of erectile dysfunction and testicular hypofunction. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to 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. Additionally, the safety and efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism. Therefore, an exception to the plans formulary coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Testosterone 1.62% Gel Pump.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gralise 600 milligram tablets prescribed as directed for neuropathic pain due to venous insufficiency related to clot, radiculopathy of cervical region, spondylosis, and low back pain. 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 documentation shows your doctor prescribed Gralise to treat your neuropathic pain due to venous insufficiency related to clot, radiculopathy of cervical region, spondylosis, and low back pain. However, the Medicare approved compendia do 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 Gralise.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle Lite test strips prescribed for the treatment of diabetes.We received the case to perform 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.We determined that the plan is not required to cover Freestyle Lite test strips. Supplies for testing and monitoring blood glucose levels are not considered Part D drugs. Although this item is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. This decision does not address the medical necessity or appropriateness of the testing strips. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide EC 3 milligram capsule prescribed three capsules a day for ulcerative colitis. The Part D plan denied your request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. Your medical records show your doctor prescribed Budesonide EC to treat your ulcerative colitis. Your 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 Budesonide EC 3 milligram capsules. The medical records do not support you have Crohns disease. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.