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

At issue is Tremfya (Guselkumab) 100 milligrams/milliliter prescribed subcutaneous to treat psoriasis. The Part D plan denied the non-formulary 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.Tremfya is not on your plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan. Additionally, there is no explanation of why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate Hydrochloride 10mg.  At initial determination and redetermination the diagnosis of unspecified mood disorder 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 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 reconsideration a diagnosis of fatigue after chemotherapy was given. No medical records were provided by the prescriber to support this 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 Linezolid 600 milligram tablets to treat inflammatory condition of the vagina, colovaginal fistula. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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 submitted documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans prior authorization criteria. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Invokana prescribed for the enrollees condition. The Part D plan denied your request. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read all documentation submitted.The documentation does not include a diagnosis or any medical records. We are unable to determine the drug was for a medically accepted indication without a diagnosis and medical records.A physician reviewed your appeal and determined that the plan is not required to cover Invokana.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligram per 2 milliliter auto-injector to treat atopic dermatitis. 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 reviewed all documentation submitted. .The enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan would likely cause harm or not be as effective for the enrollee as the requested drug. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 100 milligrams to be given two times a day for left arm pain. The Part D plan denied the drug because it was not medically necessary. The plan requires prior approval before covering some drugs. If prior approval is not obtained, the plan may not cover the drug. 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.Pregabalin is being requested to treat left arm pain. 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 Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Brilinta 90 milligram tablet to treat the enrollees condition. 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.Brilinta 90 milligram tablet is a brand drug on Tier 4 of the plans formulary.There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception. Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rexulti 1 milligram tablet prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for a lower cost-sharing tier. 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.Rexulti is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier 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: Favorable

At issue is Xifaxan tablets 550 mg (60/30) for prophylaxis against Hepatic encephalopathy. 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 appeal carefully. We reviewed all documentation available.The documentation satisfies the plans coverage criteria. The enrollee has tried and had an inadequate response to lactulose. Office notes which support this appeal were provided. The prescriber is a gastroenterologist. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 50 milligrams prescribed for chronic migraines. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Ubrelvy 50 milligrams to treat your chronic migraines. The plan requires prior authorization criteria for this drug to 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 Ubrelvy 50 milligrams because the plan requires prior authorization before covering some prescription drugs.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ambien CR 12.5 milligram tablets prescribed daily for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue was covered as a formulary exception and was not eligible 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.Ambien CR 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

At issue is Uroxatral 10 milligram tablets to treat benign prostatic hyperplasia without urinary tract obstruction/LUTS. The Part D plan denied your request because the documentation did not 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 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 prescriber has not indicated 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Uroxatral 10 milligram tablets. A physician reviewed your appeal and determined that the plan is not required to cover Uroxatral 10 milligram tablets because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xifaxan 550 milligram tablets to treat irritable bowel syndrome. 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. This drug is being provided by the plan at the cost sharing level of the Specialty Tier. Specialty Tier drugs are not available for a tiering exception per Medicare rules.  Our Physician Reviewers opinion is that the plan is not required to provide a tiering exception for Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Everolimus 5 milligrams prescribed twice daily for metastatic liver cancer. The Part D plan denied your request because the information did not support the quantity limit 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.Everolimus is ordered to treat the enrollees condition. The prescriber statement does not indicate a higher strength tablet would be ineffective in the treatment of this condition or would likely impact compliance. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover the requested quantity of Everolimus 5 milligrams per 28 days.A physician reviewed your appeal and determined that the plan is not required to cover the Everolimus, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Meprobamate 400 milligram oral tablets prescribed daily for anxiety. The Part D plan denied your request 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 prescriber has not indicated 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. Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch to treat chronic back pain due to herniated discs. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted.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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxycontin ER 15 milligram tablets prescribed three times daily for chronic pain. The Part D plan denied your request for a quantity limit exception request. We received an expedited 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 documentation indicates your doctor prescribed Oxycontin ER to treat chronic pain. Your doctor did not provide sufficient explanation as to why an exception to the quantity limit should be met. Your plan placed a quantity limit of 60 tablets per 30 days. An exception to the quantity limit criteria was not met.Therefore, the plan is not required to cover Oxycontin ER for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed for non-24 hour sleep/wake cycle disorder. The Part D plan denied coverage because the prior authorization criteria were not met. 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 records submitted at the reconsideration level. The prescriber statement provided does not show the enrollee has satisfied the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium Gel 1% to treat an unspecified diagnosis. 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.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan would likely cause harm or not be as effective as the requested drug. 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 Prevymis 480 milligram tablets prescribed to treat prophylaxis of cytomegalovirus infection in lung transplant recipient. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Cosopt PF 2%/0.5% drops to treat the enrollees condition.   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.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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pregabalin 50 milligram capsules prescribed three times daily for an unknown diagnosis.  The Part D plan denied your request because medical necessity was not established.  As well, the requested drug has prior authorization criteria.  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 request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Breo Ellipta 200/25 micrograms prescribed for an unknown diagnosis. 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. 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 state the diagnosis since the diagnosis was not contained within the appeal. The prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. 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 Singulair 10 mg tablet to treat spina bifida and seafood allergy.   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 prescriber has not indicated why all alternatives required by the plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine Patch 1.3% to treat radial styloid tenosynovitis and unspecified hip pain.  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 this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira Pen 40 milligram/.4 milliliter to treat granuloma annulare. 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 this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Venofer 300 mg to treat iron deficiency anemia.  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.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.  A physician reviewed your appeal and determined the plan is not required to cover Venofer.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tetrabenazine 12.5 milligrams one table twice daily to treat chorea.   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.The medical records show you have Huntingtons disease.  You are ordered not to have anything by mouth and have a feeding tube.  The plan formulary alternative Deutetrabenazine is a drug that cannot be crushed.  Use of that drug therapy is not tolerable for your medical status.The documentation satisfies the plans coverage criteria.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.