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

You requested a tier exception for Lidocaine 5 percent topical patch prescribed for postherpetic neuralgia, other postherpetic nervous system. The Part D plan denied your request for a tiering exception because Lidocaine 5 percent topical patch is a generic Tier 4 drug and the lower cost-sharing tiers do not contain alternative drugs to support your condition. 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 record shows Lidocaine 5 percent topical patch is being prescribed for postherpetic neuralgia, other postherpetic nervous system. The Medicare approved compendium, supports the use of the requested drug for your condition. The plan shows Lidocaine 5 percent topical patch is a generic Tier 4 drug. The lower cost-sharing tiers do not contain alternative drugs to support your condition.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Myrbetriq ER 25 milligram tablets prescribed daily for overactive bladder. The Part D plan denied your request for a tiering exception because Myrbetriq is a brand name Tier 3 drug and there are no alternative brand name drugs on lower cost-sharing tiers. 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 Myrbetriq ER is a brand name Tier 3 drug. There are no brand name 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 Cosentyx 150 milligram/milliliter pen prescribed for the enrollees moderate to severe plaque psoriasis. 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 moderate to severe plaque psoriasis. 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 Sirolimus 1 milligram tablets 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 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 medical records show the requested drug is being prescribed to treat the enrollees condition. The enrollees medical history includes a kidney transplant in December 2003. According to Medicare, the enrollee was under Medicare Part A coverage at the time of the kidney transplant. Based on the information provided, we have determined the requested drug is not eligible for Medicare Part D coverage, but would be covered under Part B.A physician reviewed your appeal and determined that the requested drug is not eligible for Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Diclofenac Epolamine 1.3 percent transdermal patch prescribed for cervicalgia and lumbago. 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 Diclofenac Epolamine 1.3 percent transdermal patch for cervicalgia and lumbago. In review of the Medicare approved compendium, cervicalgia and lumbago are not medically accepted indications for Diclofenac Epolamine 1.3 percent transdermal patch. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Diclofenac Epolamine 1.3 percent transdermal patch at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cimzia 400 milligrams per 2 milliliter syringe kit prescribed to treat rheumatoid arthritis and irritable bowel syndrome without constipation. The Part D plan denied the request because the plans prior authorization requirement for the coverage of Cimzia were not met. 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

You requested Albuterol 2.5milligrams/ 3 milliliter nebulizer solution prescribed as directed 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Albuterol 2.5milligrams/ 3 milliliter nebulizer solution to treat your chronic obstructive pulmonary disease. 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 2.5milligrams/ 3 milliliter nebulizer solution 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 2.5milligrams/ 3 milliliter nebulizer solution to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Verzenio 150 milligrams to be given two times a day for metastatic breast cancer. 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.Verzenio is being requested to treat metastatic breast cancer human epidermal growth factor receptor 2 (HER2) positive. The Medicare approved compendia, including NCCN,  do not support the use of this drug for the enrollees condition. No article from the medical literature is provided.A physician reviewed your appeal and determined that the plan is not required to cover the Verzenio.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dofetilide 500 microgram capsules prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the prescriber did not address all alternatives were tried and failed. 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.Dofetilide is a generic drug on Tier 4 of the plans formulary. Your doctor submitted a supporting statement. The statement did not address why all alternative lower-tier medication on the plans formulary would not work for you. All generic drugs on lower tiers have not been tried. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Gabapentin 100 milligram capsules. The Part D plan denied the request because the prescriber confirmed the medication was being used for the treatment of a hospice related illness and Medicare Part A covers all drugs used in hospice treatment. Therefore, the medication could not be covered by the Part D plan. 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 prescriber has stated that the enrollee is no longer in hospice care. However, for coverage under Medicare Part D after leaving hospice care, notification must be received in writing with a date of termination, which must be prior to the date of service for the medication. There is no documentation in the file indicating the enrollees date of termination of hospice care. Therefore, it is not possible to determine if the enrollee left hospice care prior to the date the medication was prescribed.We have determined that the plan is not required to cover the Gabapentin.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Aimovig 140 milligram/milliliter autoinjector prescribed once monthly for migraine prophylaxis. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription biologics. If prior approval is not obtained, the plan may not cover the biologic. 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 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 medical records show you prescribed Aimovig 140 milligrams/milliliter autoinjector to treat the enrollees migraine with aura. The Medicare approved compendia do support the use of this biologic for this condition. The plan requires evidence of significant clinical improvement for continuation therapy before they will cover the requested biologic. The medical records submitted support significant clinical improvement as evidence by a reduction in headaches from 14 per month to six per month. The documentation provided does show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Aimovig 140 milligram/milliliter autoinjector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira Pen 40 milligrams prescribed for the treatment of sarcoidosis. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received ax 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 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.A physician reviewed your appeal and determined  that the plan is not required to cover Humira Pen because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Omeprazole-Sodium Bicarbonate 40 milligram-1.1 gram capsules. 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 Omeprazole-Sodium Bicarbonate has been prescribed to treat the enrollees gastroesophageal reflux disease with esophagitis without hemorrhage. However, the prescriber has not sufficiently addressed why all alternatives required by the plan to treat this condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide-Formoterol 160/4.5 microgram inhalation powder prescribed for chronic obstructive pulmonary 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 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 Budesonide-Formoterol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac sodium 1% transdermal gel prescribed three times daily for shoulder pain. 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 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 Diclofenac sodium gel for your condition. 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 Diclofenac sodium gel because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benicar 40 milligram tablets prescribed daily for hypertension. The Part D plan denied your request for a tiering 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. The requested drug is being provided by your plan under a formulary exception. Benicar is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zortress .75 milligram tablets prescribed for kidney transplant. The Part D plan denied the request because the enrollees transplant was in a Medicare approved facility covered by Part A. Therefore, anti-rejection drugs are covered under Part B. We received a 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 determined that the plan is not required to cover the Zortress. Medicare records indicate the enrollee received a kidney transplant on August 17, 2019, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Zortress is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. Please submit your request to Medicare Part B. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colesevelam HCl 3.75 gram packet prescribed 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 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.Colesevelam HCl 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

You requested compounded Naltrexone 4.5 milligram capsules prescribed to treat the enrollees condition. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. The record shows the Natrexone was compounded and the enrollee paid out of pocket and is seeking reimbursement. We asked the prescriber to send us the National Drug Code of all items in the compound as well as an itemized receipt. However, we did not receive the documentation.A physician reviewed your appeal and determined that the plan is not required to reimburse you for the Naltexone 4.5 milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Temozolomide 140 milligram tablets prescribed for other specified types of non-hodgkin lymphoma. The Part D plan denied your request because the drug at issue is covered under Medicare Part B. 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 physician prescribed Temozolomide to treat your diagnosis of non-hodgkin lymphoma. The Medicare approved compendia support this is a medically accepted indication for the drug. However, the drug at issue is an oral cancer drug that has the same active ingredient as an injectable drug. Oral cancer drugs that contain the same active ingredient as injectable dosage forms are covered under Medicare Part B. The drug at issue is not considered a Part D benefit.We determined that the plan is not required to cover the Temozolomide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 145 microgram capsules prescribed one daily for chronic idiopathic constipation. 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.Linzess is a brand drug on Tier 4 of the plans formulary. Your doctor submitted a supporting statement. The statement said Colace, Lactulose, Probiotics, Miralax, and Metamucil could not help you. However, your doctor did not address why not all alternative lower-tier medication on the plans formulary would work for you. Not all brand drugs on lower tiers have been tried. 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 Levalbuterol HCL inhalation solution. The Part D plan denied your request because you did not have a medically accepted indication for this drug. 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 documentation indicates that Levalbuterol HCL was prescribed to treat bronchitis secondary to Covid-19. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Levalbuterol HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symbicort 160-4.5 micrograms/actuation inhaler prescribed as directed for chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception because there were no brand drugs of the same type on the lower cost sharing tiers. 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. Symbicort 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.