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

At issue is Sildenafil 20 milligrams prescribed as directed for pulmonary arterial hypertension. 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 was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the plans prior authorization criteria. A response from the prescriber was not received. Your medical records show you were prescribed Sildenafil to treat your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided do not show the plan's coverage criteria have been met.A physician reviewed your appeal and determined that the plan is not required to cover the Sildenafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Morphine Sulfate Extended Release 30 milligram tablet INSERT prescribed for pain. The Part D plan auto-forwarded the case to us for determination. 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 asked the prescriber to send us a prescriber statement and medical records. The requested documentation was not received.Morphine Sulfate Extended Release was prescribed for you. The documentation submitted is not sufficient to determine the medical necessity for this drug. As such, a determination cannot be made at this time.We determined that the plan is not required to cover Morphine Sulfate Extended Release because the information in the case file is not sufficient to determine medical necessity.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Testosterone 1 percent 50 milligrams per 5-gram gel prescribed for hypogonadism. 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

At issue is Vumerity 231 milligram capsules prescribed for multiple sclerosis. 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. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Vumerity.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Methotrexate 2.5 milligrams prescribed for morbid severe obesity due to excess calories. The Part D plan denied your request for a tiering exception because Methotrexate is a generic Tier 3 drug and there are no drugs of the same type on the lower cost sharing levels. 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. The plan shows Methotrexate is a generic Tier 3 drug. There are no drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dupixent 300 milligram/2 milliliter injection prescribed for pruritus of the skin. The Part D plan denied your request because the biologic 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 submitted documentation indicates your doctor prescribed Dupixent for pruritus of the skin. The Medicare approved compendia do not support the use of this biologic for your condition. As the biologic was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Ursodiol 300 milligram capsules prescribed for biliary cirrhosis unspecified. The Part D plan denied your request for a tiering exception because Ursodiol is a generic Tier 3 drug and there are no drugs of the same type on the lower cost sharing levels. 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. The plan shows Ursodiol is a generic Tier 3 drug. There are no drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica 300 milligram capsule prescribed three times daily for lumbar degenerative disc disease. 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 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 asked your prescriber to send us a prescriber statement and information regarding your condition. We also asked for medical records or other documentation to show why the medication was needed. 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.A physician reviewed your appeal and determined that the plan is not required to cover Lyrica.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis 0.05% ophthalmic emulsion prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. We received 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.Restasis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine HCl 10 milligram tablets prescribed for the enrollees anxiety and depression. 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 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. The documentation supports the drug was prescribed for the enrollees diagnosis of anxiety and depression. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.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 Acyclovir 5% ointment prescribed as directed for non-life threatening mucocutaneous herpes simplex virus infection in an enrollee that is not immunocompromised. 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 prescriber statement shows the doctor prescribed Acyclovir ointment for non-life threatening mucocutaneous herpes simplex virus infection in an enrollee that is not immunocompromised. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Acyclovir ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Edarbyclor (Azilsartan Medoxomil 40 milligrams/Chlorthalidone 12.5 milligrams) prescribed for hypertension. 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 Guanfacine hydrochloride 1 milligram tablets prescribed as directed. At initial determination and redetermination, the diagnoses of bipolar disorder, unspecified, and alcohol dependence, in remission, were given. 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. At reconsideration, diagnoses of attention-deficit hyperactivity disorder and hypertension were given. No medical records were provided by the prescriber to support these diagnoses. 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.A physician reviewed your appeal and determined that the plan is not required to cover Guanfacine hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Guanfacine hydrochloride 2 milligram tablets prescribed as directed. At initial determination and redetermination, the diagnoses of bipolar disorder, unspecified, and alcohol dependence, in remission, were given. 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. At reconsideration, diagnoses of attention-deficit hyperactivity disorder and hypertension were given. No medical records were provided by the prescriber to support these diagnoses. 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.A physician reviewed your appeal and determined that the plan is not required to cover Guanfacine hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Spiriva Respimat 2.5 micrograms/actuation inhalation spray prescribed as directed for restrictive lung disease and shortness of breath. 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 medical records show the doctor prescribed Spiriva for restrictive lung disease and shortness of breath. However, the Medicare approved compendia do not support the use of this drug for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to cover Spiriva.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate mofetil 500 milligram tablets prescribed as directed for polymyositis. The Part D plan denied your request because the drug might be covered by Medicare Part B. The Part D plan also 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 medical records show the doctor prescribed Mycophenolate mofetil to treat polymyositis. The documentation does not show that the medication was prescribed following a Medicare-covered organ transplant. Therefore, the drug would not be covered under Medicare Part B, and is eligible for consideration of Medicare Part D coverage. However, the Medicare approved compendia do not support the use of Mycophenolate mofetil for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Esomeprazole 40 milligram delayed release capsules prescribed for gastroesophageal reflux disease, irritable bowel syndrome, and gastritis. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication, and the documentation did not support a quantity limit 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 submitted documentation indicates your doctor prescribed Esomeprazole for gastroesophageal reflux disease, irritable bowel syndrome, and gastritis. You have been on the medication since 2010. The Medicare approved compendia do not support the use of this drug for your condition. The drug at issue is medically indicated for short-term relief of gastroesophageal reflux disease. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed. As the drug is denied, a quantity limit exception cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate 10 milligram tablets prescribed for multiple sclerosis. 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 submitted documentation indicates your doctor prescribed Methylphenidate for multiple sclerosis. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rytary 48.75 milligram-195 milligram capsules. The Part D plan denied your request because off-formulary criteria were not met. 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. Your doctor submitted a statement that you had tried and failed carbidopa/levodopa ER tablets. However, there were no medical records submitted to support this statement or to support a prescribed diagnosis. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amphetamine-Dextroamphetamine 30 milligrams to be given two times a day for attention-deficit/hyperactivity disorder. The Part D plan denied the request. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read the 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 asked you to send us a statement and information regarding the enrollees condition. We also asked for medical records to show why this drug was needed. We did not receive the documentation requested.A physician reviewed your appeal and determined that the plan is not required to cover the Amphetamine-Dextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine-Naloxone 8-2 milligram sublingual tablets prescribed for opioid dependence and chronic pain. 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. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine-Naloxone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clobazam 20 milligram tablets prescribed for epilepsy, unspecified, intractable, without status epilepticus. 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 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. The documentation supports the drug was prescribed for the enrollees diagnosis of epilepsy, unspecified, intractable, without status epilepticus. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.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 Ondansetron Hydrochloride 4 milligram tablets prescribed for nausea and vomiting, unspecified. The Part D plan denied the request because the medication was prescribed for a non-medically accepted indication. We received an auto-forwarded reconsideration request from the coverage level. We performed an independent and de novo review. To make our decision, we read 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 Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. 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 Ondansetron Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Repatha Pushtronex System, 420 milligrams per 3.5 milliliters. The Part D plan denied your request because the medication was not included on the plans formulary and 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. The documentation supports that the Repatha Pushtronex System has been prescribed in the management of the enrollees hyperlipidemia in the presence of atherosclerotic heart disease of native coronary artery without angina pectoris. However, the prescriber has not sufficiently addressed why all alternative drugs included in the plan to treat this condition have been tried and failed or would likely not be as effective as the requested drug or would likely cause adverse reactions or other harm. Our physician reviewer's opinion is that formulary exception criteria are not met.