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

At issue is Saxenda to treat morbid obesity.   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.Drugs prescribed to treat weight gain (promote weight loss) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trintellix 10 milligrams tablet prescribed for depression. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows Trintellix 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 for the enrollees condition. 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 Trintellix.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Venclexta 100 milligram tablet prescribed four tablets daily for progressive multiple myeloma. 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. Your medical records show your doctor prescribed Venclexta to treat your progressive multiple myeloma with t(11;14) chromosome translocation in conjunction with dexamethasone. The medical records also indicate that you have been previously treated with Bortezomib/Cyclophosphamide/Dexamethasone (VCD) and Lenalidomide/Bortezomib/Dexamethasone (VRd) cycles.The Medicare approved compendia do support the use of this drug for your condition. Specifically, the National Comprehensive Cancer Network supports the use of Venclexta in therapy for previously treated multiple myeloma for progressive disease in combination with dexamethasone for patients with t(11;14). The plan also requires prior authorization criteria be met before they will cover the requested drug. The plans prior authorization criteria does not include specific conditions, which must be met for your specific diagnosis. The documentation provided supports that an exception to the plans prior authorization criteria has been met. An oncologist reviewed your appeal and determined that the plan is required to cover Venclexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Reclast 5 milligram/100 milliliter intravenous infusion prescribed for osteoporosis. The Part D plan denied your request because the documentation did not support an off-formulary 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. This intravenous infusion drug may be eligible for coverage under Medicare Part B if it is infused in the home using durable medical equipment, or provided incident to a physicians services. In addition, the documentation does not rule out the enrollees ability to take all of the other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Reclast.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mesalamine 1.2 gram capsule prescribed three times per day for microscopic colitis. 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 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.Mesalamine 1.2 gram capsule was ordered for microscopic colitis. 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 cover the Mesalamine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for the Dexcom G6 transmitter. The Part D plan denied your request because prior authorization was not received. We received an auto-forwarded reconsideration request from the plan. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We determined that the plan is not required to reimburse you for the Dexcom G6 transmitter because Medicare Part D does not cover devices. Dexcom G6 has been classified by the Food and Drug Administration as a device, not as a drug. 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 Prolastin-C 60 milligrams per kilogram weekly. The Part D plan denied the drug because there was no diagnosis or information to support a medically accepted indication. The plan requires prior approval before covering some 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 records submitted at the reconsideration level.Prolastin-C is being requested to treat the enrollees condition. We asked the prescriber to send us a supporting statement and medical records. We did not receive the documentation requested. There is no documentation to support a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover the Prolastin-C.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Eliquis 5 milligram tablets prescribed for the diagnosis of paroxysmal atrial fibrillation. The Part D Plan denied your request stating that the drug is already being provided at the lowest cost-share amount allowed. We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare rules and the plans formulary.Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower Tiers 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 Eliquis at a lower Tier cost.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tenormin 50 milligram tablets to treat essential hypertension. The Part D plan denied your request because the documentation did not support an off-formulary 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. 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 Tenormin 50 milligram tablets. A physician reviewed your appeal and determined that the plan is not required to cover Tenormin 50 milligram tablets because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocort-Pramoxine (perianal) cream 2.5/1% to treat third degree hemorrhoids.  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 plan denied the request for coverage of the requested drug to treat the provided diagnosis because your plan's Medicare Part D drug plan cannot cover drugs classified as being part of the Food and Drug Administration (FDA)'s Drug Efficacy Study Implementation (DESI) program. These drugs are considered to be Less than Effective (LTE) per FDA review.A physician reviewed your appeal and determined that the plan is not required to cover the Hydrocort-Pramoxine cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100-62.5-25 microgram inhaler prescribed daily for interstitial lung disease. 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.Trelegy Ellipta 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 grant the tiering exception. There are no lower tiered generic drugs of the same type to treat the enrollees condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate Hydrochloride 20 milligram oral tablets. 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. Methylphenidate Hydrochloride 20 milligram tablet a generic drug on Tier 3 of the plans formulary. There are no generic 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 Ozempic subcutaneous injection pen prescribed at a dosage of 0.5 milligrams weekly for type II diabetes mellitus. 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 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. Ozempic 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

You requested a Shingrix Vial Kit prescribed for shingle prevention. The Part D plan denied your request because you did not include the proof of payment from your doctors office. 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.You state that you received a shingles vaccination on November 30, 2020. You were asked by your plan to submit a proof of payment from your doctors office. You did not submit the proof of payment to your plan. We determined that the plan is not required to cover the Shingrix Vial Kit because you have not submitted the proof of payment from your doctors office to your plan verifying payment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 600 microgram/24 milliliter injector pen 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 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.Forteo 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: Unfavorable

You requested Diazepam 5mg vaginal suppositories prescribed for pelvic floor pain. The Part D plan denied your request to cover the requested compounded medication. 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 a compounded drug. 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 vaginally, for the treatment of your 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 compounded diazepam for your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Flovent HFA 220 microgram inhaler 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 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.Flovent HFA 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 Elmiron 100 milligram capsules prescribed three times daily 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 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.Elmiron 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 grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Qnasl 80 microgram nasal spray prescribed daily for allergic rhinitis. The Part D plan denied your request because the documentation did not support an off-formulary 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. A physicians statement was submitted and stated you had tried Fluticasone. Medicare approved compendia supports the use of the requested drug for your condition.medicaHowever, the records do not show why you cannot take other drugs on your plans formulary for your condition. Specifically, Flunisolide nasal spray and Ipratropium Bromide.A physician reviewed your appeal and determined that the plan is not required to cover Qnasl.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Victoza 0.6 milligram subcutaneous injections prescribed as directed. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. The Part D plan also denied your request because the reported indication for this drug excludes it from Part D coverage. 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 documentation shows the doctor prescribed Victoza for an enrollee with obesity and hypothyroidism. However, the Medicare approved compendia do not support the use of Victoza for the enrollees condition. Additionally, drugs used for weight loss are excluded from coverage by Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Victoza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 25 milligram tablet prescribed as directed to treat overactive bladder, urge incontinence. The Part D plan denied the tiering 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 information submitted at the reconsideration level.Myrbetriq ER 25 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 Oxycontin Extended Release 20 milligram tablets to treat chronic 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 prescriber has not indicated why all alternatives that are covered 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. Our Physician Reviewers opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Esbriet 267 milligram tablets prescribed for the enrollees idiopathic pulmonary fibrosis. 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 idiopathic pulmonary fibrosis. 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 Albuterol Sulfate 2.5 milligrams/3 milliliter solution prescribed for asthma. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows your doctor prescribed the medication for asthma. The documentation supports you are using the medication via nebulizer in your home. Inhalation medication used in a nebulizer at home is covered under Medicare Part B.We determined that the plan is not required to cover Albuterol Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 1% gel prescribed for the enrollees severe multi-joint osteoarthritis. 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 severe multi-joint osteoarthritis. 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 Pyridostigmine Bromide 60 milligrams tablets. The Part D plan denied a request for a tiering exception for this drug because you did not have 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 physician submitted a supporting statement. The prescriber statement indicates that Pyridostigmine Bromide is prescribed for autonomic dysfunction with myasthenic symptoms. 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 Pyridostigmine Bromide.