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

You requested Cresemba, 186 milligram tablets for the treatment of tenosynovitis secondary to disseminate histoplasmosis infection. The Part D plan denied your request because histoplasmosis infection is not a Food and Drug Administration-approved diagnosis for the use of this medication. 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.  A physician reviewed your appeal and determined that the plan is not required to cover the Cresemba because histoplasmosis infection is not a medically accepted indication to use this drug.The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, the requested drug does not meet the definition of a Medicare Part D drug and, therefore, is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Modafinil 200 milligrams prescribed daily for major depressive disorder, recurrent, moderate and insomnia due to other mental disorder. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Modafinil for major depressive disorder, recurrent, moderate and insomnia due to other mental disorder. In a statement dated 2/8/21, the prescriber states the enrollee has insomnia due to depression.  We asked your doctor to send us a supporting statement to show why Modafinil is medically necessary for you. No additional documentation was received.In review of the Medicare approved compendia, major depressive disorder, recurrent, moderate and insomnia due to other mental disorder is not a medically accepted indication for Modafinil. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Modafinil at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Olopatadine Hydrochloride 2% solution ordered daily for dry eye syndrome and bilateral vitreous degeneration. The Part D plan denied the request for a tiering exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The plan indicated the drug was approved under current Tier 4 level of cost sharing.Olopatadine Hydrochloride 2% solution was ordered to treat the enrollees conditions. However, there are no drugs in the formulary of the same type on lower tiers to treat your condition. The prescriber has also not indicated what other medications have been tried and failed, were ineffective, or could not be tried for medical reasons.A physician reviewed your appeal and determined that the plan is not required to cover Olopatadine Hydrochloride 2% solution at a lower cost sharing tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Januvia 100 milligrams prescribed as directed for diabetes mellitus. The Part D Plan denied your request for a tiering exception. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The record shows you were prescribed Januvia 100 milligrams as directed for diabetes mellitus. Januvia 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 cover the Januvia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise 600 milligram tablet, quantity 90 per 30 days prescribed for chronic pain syndrome and fibromyalgia. The Part D plan denied your request for a non-formulary drug. The plan indicated you did not have a medically accepted indication for this drug. 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 Gralise was prescribed to treat chronic pain syndrome and fibromyalgia. However, the Medicare approved compendia do not support the use of this specific drug dosage for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to cover Gralise. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligrams ordered as directed for hypercholesterolemia. The Part D plan denied your request because off-formulary exception rules were not met. 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 this level.Repatha was ordered to treat the enrollees hypercholesterolemia. Medicare approved compendium supports the use of the drug for this condition. However, the records do not show why the enrollee cannot take all other drugs on the plans formulary for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Colcrys 0.6 milligrams prescribed as directed for calcium pyrophosphate dihydrate crystal deposition disease (CCPD) also referred to as psuedogout. The Part D plan denied the request because it does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The record shows you were prescribed Colcrys 0.6 milligrams as directed for CCPD. 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 the Colcrys because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Doxycycline Hyclate 150 milligrams prescribed as directed for rosacea. The Part D plan denied your request for a tiering exception because the drug you requested is not included on your plans formulary.  We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The record shows you were prescribed Doxycycline Hyclate 150 milligrams as directed for rosacea. The Medicare approved compendia support the use of this drug for your condition. Your plan approved this non-formulary drug. However, since the drug isnt on the plans formulary it is not eligible for a tiering exception. Therefore, the drug cannot be considered for a tiering exception under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Doxycycline Hyclate as a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xanax 2 milligram tablet prescribed three times daily for anxiety. The Part D plan denied your request for a tiering exception because the requested drug is in the highest specialty tier and the plan does not allow drugs in this tier at a lower cost-share. 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. Xanax 2 milligram tablet is a brand drug on Tier 4 of the plans formulary. The prescriber statement shows that generics cause itching. However, brand Xanax is on the specialty tier of 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 cover Xanax 2 milligrams at a lower cost-share.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta, 20-milligram tablet prescribed twice daily for pseudobulbar affect not related to Amyotrophic Lateral Sclerosis or Multiple Sclerosis. The Part D plan denied your request because Nuedexta is no Food and Drug Administration approved for your condition. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Nuedexta to treat your pseudobulbar affect not related to Amyotrophic Lateral Sclerosis or Multiple Sclerosis. 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 Nuedexta because you do not have a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Piqray to treat a specific type of breast cancer. 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 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. The prescriber was asked by the plan, 'Is the patient HER-2 negative?' The prescriber answered, 'No.' As well, the reconsideration appeal contained medical records which state that the enrollee's HER-2 status is, 'EQUIVOCAL.' There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Brovana 15 milligrams per 2 milliliters solution prescribed daily 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 an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows Brovana was prescribed to treat chronic obstructive pulmonary disease. However, this drug is eligible for coverage under Medicare Part B. A nebulized drug used in the home or in an assisted living facility could be covered under Medicare Part B.We determined that the plan is not required to cover Brovana.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent injection prescribed for atopic dermatitis/eczema. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. 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 Dupixent was prescribed to treat eczema.  Dupixent is on the plans formulary specialty tier and is not eligible for a tiering exception.  A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sensipar 30 milligram tablet for secondary hyperparathyroidism. The Part D plan denied your request to cover this drug at a lower tier cost. The plan indicated this is a non-formulary drug and cannot be provided at a lower tier cost. 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 Sensipar was prescribed to treat hyperparathyroidism.   Sensipar is a non-formulary approved drug and is not eligible for a tiering exception.  A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the Sensipar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligram tablets prescribed once daily for overactive bladder. 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.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 your appeal and determined that the plan is not required to cover Myrbetriq at a lower cost-sharing tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Keppra XR 750 milligrams two tablets daily for focal and partial epilepsy. The Part D plan denied your request for a tiering exception because the drug is not on the plans formulary. 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. Keppra XR 750 milligram tablet is a brand drug that is not on the plans formulary. The enrollee has been approved for a formulary exception for this medication. An enrollee may not request a tiering exception for a non-formulary prescription drug approved for a non-formulary exception. 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 Keppra XR 750 milligram tablets at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lamictal XR 200 milligrams two tablets daily for focal and partial epilepsy. The Part D plan denied your request for a tiering exception because the drug is not on the plans formulary. 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. Lamictal XR 200 milligram tablet is a brand drug that is not on the plans formulary. The enrollee has been approved for a formulary exception for this medication. An enrollee may not request a tiering exception for a non-formulary prescription drug approved for a non-formulary exception. 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 Lamictal XR 200 milligram tablets at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Flector 1.3% patch, prescribed every twelve hours, 180 patches per 90 days with refills for severe acute spasm. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber initially stated that the requested drug was for the treatment of acute spasm. The prescriber stated the enrollee has tried Ibuprofen, Naproxen, Celebrex and Mobic and that the requested drug was for a refill, not newly prescribed.   In the request for reconsideration, the prescriber changed the diagnosis to acute pain due to contusion. Relevant medical records were requested but were not provided.  In addition, the prescriber has requested a 90 day supply with refills of a drug which is only indicated for the treatment of an acute condition.  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 Flector 1.3% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligrams prescribed twice daily for atrial fibrillation. The Part D Plan denied your request for a tiering exception. We received an expedited 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.Eliquis is a brand drug on Tier 3 of the plans formulary. The prescriber statement shows the enrollee was being treated for atrial fibrillation. 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. There are no lower tiered brand drugs of the same type to treat the enrollee's condition.A physician reviewed your appeal and determined that the plan is not required to cover Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tramadol Hydrochloride ER 100 mg to treat pain. 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 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 enrollee does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plans coverage criteria. Specifically all the questions about opioid safety were not addressed. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Revlimid 5 milligram capsules prescribed daily for monoclonal gammopathy and cryoglobulinemia. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation shows your doctor prescribed Revlimid to treat your monoclonal gammopathy and cryoglobulinemia. 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 Revlimid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Kisqali 400 milligram tablets prescribed daily for ovarian cancer. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation shows your doctor prescribed Kisqali to treat your ovarian cancer. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  A physician reviewed your appeal and determined that the plan is not required to cover Kisqali.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Privigen 40 grams/400 milliliters prescribed intravenously for nonfamilial hypogammaglobulinemia. 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 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 doctor prescribed Privigen to be administered intravenously in your home for your diagnosis of nonfamilial hypogammaglobulinemia. However, this drug is eligible for coverage under Medicare Part B. Medicare Part B pays for intravenous immunoglobulin when used in the home to treat an immune deficiency disease.We determined that the plan is not required to cover Privigen.