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

You requested Opium Tincture 10 milligrams/milliliter 0.3 milliliters prescribed four times daily for diarrhea. The Part D plan denied your request because the drug at issue was not Food and Drug Administration approved. We received an expedited auto-forwarded reconsideration request from the coverage level. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows your physician prescribed Opium Tincture for your diarrhea.  We have found that the drug is being prescribed for a medically accepted indication.  Drugdex, a Medicare approved compendia states: Paregoric (0.4 mg morphine/mL) and opium tincture (10 mg morphine/mL) may be useful for the treatment of diarrhea.  Opium Tincture is not on the Plan's formulary.  The prescriber has not stated that all of the formulary alternatives to treat the enrollee's condition would not be as effective for the enrollee and/or would have adverse effects for the enrollee.We determined that the plan is not required to cover the Opium Tincture.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Febuxostat 40 milligrams prescribed for hyperlipidemia. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Febuxostat 40 milligrams to treat your hyperlipidemia. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined  that the plan is not required to cover Febuxostat 40 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humalog Kwikpen mix 75/25 prescribed for diabetes mellitus. The Part D Plan denied your request for a tiering exception because the there are no biologic drugs of the same type on the lower cost sharing tiers. 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 record shows you were prescribed Humalog Kwikpen mix 75/25 for diabetes mellitus.  Humalog Kwikpen mix 75/25 is a biologic drug on Tier 3 of the Plan's formulary.  There are no lower tier biologic drugs of the same type on the Plan's formulary.  Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisone 5 milligram tablets prescribed daily following a kidney transplant. The Part D Plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Prednisone to prevent rejection following a kidney transplant. The Medicare approved compendia support the use of this drug for your condition.Based on the information provided, the drug is eligible for Part B coverage.  Therefore, the drug is not eligible for Part D coverage in this case.  A physician reviewed your appeal and determined that the plan is not required to cover Prednisone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine 2 milligrams sublingual prescribed daily for chronic pain syndrome. The Part D plan denied your request because the medically accepted indication criteria was not met. We received an expedited auto-forwarded 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. The medical records show Buprenorphine sublingual was ordered to treat chronic pain syndrome. However, the Medicare approved compendia do not support the use of this drug for this condition. The medical records submitted do not show the enrollee has a medically accepted indication for the drug.A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myobloc Solution 2500 unit/0.5 milliliters prescribed for symptoms due to Parkinsons disease. The Part D plan denied your request for a tiering exception because the drug had already been approved for a non-formulary 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. We also researched Medicare law and the plans rules.The documentation in the record shows that Myobloc Solution is covered for the enrollee through a formulary exception. Medicare law and plan rules do not allow tiering exceptions for non-formulary drugs being covered through a formulary exception. Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pradaxa, one 150 milligram capsule prescribed twice daily for atrial fibrillation. The Part D plan denied coverage because the information received from your physician did not confirm that you had tried Eliquis or Xarelto. The plan further stated that there is a restriction on this drug that has been approved by the Centers for Medicare and Medicaid Services. The plan requires that you have tried Eliquis or Xarelto previously. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show that your doctor prescribed Pradaxa to treat your atrial fibrillation. The Medicare approved compendium supports the use of this drug for your condition. However, your plan requires that you have tried taking Eliquis or Xarelto prior to being placed on Pradaxa. Additionally, the plan requires your physician to indicate that Eliquis or Xarelto would not be as effective as the requested drug and/or that the enrollee would have adverse effects before they will cover the requested Pradaxa. 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 Pradaxa because you have not tried Eliquis or Xarelto.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Uloric 80 milligrams prescribed daily for gout. The Part D plan denied your request because Probenecid was not addressed to 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 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 also researched Medicare systems and reviewed the enrollment data available.A supporting statement and medical records were submitted. The medical records show Uloric was prescribed to treat the enrollees gout. A Medicare approved compendium supports the use of the requested drug for this condition.However, the records do not show why the enrollee cannot take all other drugs on the plans formulary for gout. Although the records show the enrollee is allergic to Allopurinol and Colchicine, there is no documentation that Probenecid was tried and would not be as effective as Uloric and/or would have adverse effects for the enrollee.A physician reviewed your appeal and determined that the plan is not required to cover Uloric.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fondaparinux Sodium 5 milligrams/0.4 milliliters prescribed for coagulation defect. The Part D Plan denied your request for a tiering exception because the drug at issue was on a specialty tier. We received an expedited auto-forwarded 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.Fondaparinux Sodium 5 milligrams/0.4 milliliters is a generic drug on Tier 5 of the plans formulary. The drug is on a specialty tier.  Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Fondaparinux Sodium at a lower cost-sharing tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Donepezil 5 milligrams prescribed twice daily for severe dementia. The Part D plan denied your request because this medication is not prescribed for a medically accepted indication. 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. The records show you prescribed Donepezil 5 milligrams to treat the enrollees severe dementia. The medical records submitted do not indicate the enrollees type of dementia. The Medicare approved compendia do not support the use of this drug for this condition. There is not a medically accepted indication for Donepezil 5 milligrams for the patient's condition.A physician reviewed your appeal and determined that the plan is not required to cover Donepezil 5 milligrams. We cannot consider overturning the quantity limitations for a drug the Part D plan is unable to cover.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Verzenio 150 milligrams prescribed twice daily for recurrent abdominal liposarcoma. The Part D plan denied your request because the medication is not prescribed for a medically accepted indication. 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. The records show that you prescribed Verzenio to treat the enrollees recurrent abdominal liposarcoma. However, the Medicare approved compendia do not support the use of this drug for this condition. There were no complete journal articles provided to support a medically accepted indicationA physician reviewed your appeal and determined that the plan is not required to cover Verzenio 150 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium Bromide/Albuterol Sulfate nebulizer solution prescribed four times a day as needed, for chronic obstructive pulmonary disease. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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 Ipratropium Bromide/Albuterol Sulfate nebulizer solution was prescribed to treat chronic obstructive pulmonary disease. The requested drug is to be used in a nebulizer at home and is eligible for coverage under Medicare Part B. We determined that the plan is not required to cover Ipratropium Bromide/Albuterol Sulfate nebulizer solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azathioprine 50 milligrams prescribed daily for the diagnosis of birdshot chorioretinitis, bilateral. The Part D plan denied your request because the diagnosis provided is not a medically accepted indication for the requested 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 information submitted at the reconsideration level. We also researched Medicare approved compendia and the plan's formulary.The medical records show your doctor prescribed Azathioprine to treat birdshot chorioretinitis. The Medicare approved compendia do not support the use of this drug for your condition. Medicare law defines those drugs that may be covered under Part D and a covered prescription drug must be used for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcipotriene/Betamethasone dipropionate (0.005%/0.064%) topical ointment prescribed for dyshidrotic eczema. You requested that the plan provide coverage for a non-formulary 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. The prescriber statement shows Calcipotriene/Betamethasone was prescribed to treat dyshidrotic eczema. However, the Medicare approved compendia do not support the use of this drug for dyshidrotic eczema. A physician reviewed your appeal and determined that the plan is not required to cover Calcipotriene/Betamethasone. The drug has not been prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol 2.5 milligrams prescribed every six hours for asthma. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Albuterol 2.5 milligrams every six hours to treat your asthma. The Medicare approved compendia do support the use of this drug for your condition. However, we determined that the drug is not eligible for Part D coverage. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover Albuterol 2.5 milligrams because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit.You may wish to submit a request for Albuterol 2.5 milligrams to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mesalamine Delayed Release, one 800 milligram tablet prescribed six-times-daily for your ulcerative colitis. Your Part D plan denied a tiering exception because your drug is not covered or listed on your plans formulary. However, your plan did approve Mesalamine Delayed Release, 800 milligrams for you under a non-formulary exception. The plan further stated that Medicare does not grant a tiering exception (reduction in co-pay) for a lower cost-sharing amount for drugs that are not covered on their plan's formulary, including non-formulary drugs you may have asked to be covered as an exception. Because of the Centers for Medicare and Medicaid Services restriction, your request for a lower cost-sharing amount could not be approved. As such, Mesalamine Delayed Release, 800 milligrams did not qualify for a tiering exception per Medicare rules. We received a tiering exception reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Mesalamine Delayed Release, one 800 milligram tablet for your ulcerative colitis. The Medicare approved compendium supports the use of the requested drug for your condition. However, Mesalamine Delayed Release, 800 milligram tablet is a drug that is not covered by your plan. Additionally, your plan approved Mesalamine Delayed Release, one 800 milligram tablet for you to take under a non-formulary exception. There are no drugs of the same dosage on the lower cost sharing tiers for you to try. Lastly, Medicare does not allow a tiering exception for a non-formulary drug that is approved as a non-formulary exception. Therefore, the requested drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that your plan is not required to grant a tiering exception (reduction in co-pay) for Mesalamine Delayed Release, 800 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus 100 units per milliliter prescribed daily for type 2 diabetes mellitus. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an auto-forwarded 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 systems and reviewed the enrollment data available.Your physician submitted a supporting statement and medical records. The medical records show the physician had prescribed Lantus 100 units per milliliter to treat your type 2 diabetes mellitus. The Medicare approved compendium supports the use of the requested drug for your condition.However, the records do not show why you cannot take other drugs on your plans formulary for your condition. Specifically, your physician submitted a prescriber statement that indicates you have never tried any alternative drugs to treat your type 2 diabetes mellitus. Your medical records do not show all alternative drugs on the plan formulary have been tried or why you cannot take them.A physician reviewed your appeal and determined that the plan is not required to cover Lantus 100 units per milliliter because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ilumya 100 milligrams per milliliter prescribed for hidradenitis suppurativa. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Ilumya 100 milligrams per milliliter to treat your hidradenitis suppurativa. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined  that the plan is not required to cover Ilumya 100 milligrams per milliliter because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine 2 milligram sublingual tablets prescribed three times daily for chronic pain syndrome. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication, and your request for a quantity limit exception was denied as the drug was denied coverage. We received a reconsideration request. You changed the quantity requested to a covered quantity.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 submitted documentation indicates your doctor prescribed Buprenorphine to treat your chronic pain syndrome. 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 Buprenorphine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine-Naloxone 8 milligrams/2 milligrams film prescribed three times per day for an opioid-use disorder and chronic pain. The Part D plan denied your request for an off-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 information submitted at the reconsideration level.The medical records show Buprenorphine-Naloxone 8 milligrams/2 milligrams film was prescribed to treat an opioid-use disorder and chronic pain. The requested drug is not on the plans formulary. The prescriber statement shows that Buprenorphine-Naloxone tablet would be appropriate for the enrollees condition. The plans formulary includes Buprenorphine-Naloxone in tablet form. However, the medical record fails to document that all formulary alternatives have been tried and failed, would cause adverse effects, or are contraindicated.A physician reviewed the appeal and determined that the plan is not required to grant a formulary exception for this drug.