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

At issue is Omeprazole/Sodium bicarbonate 40-1000 milligram capsules to treat the enrollees condition. The Part D plan denied your request.We received the case to perform 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.Omeprazole/Sodium bicarbonate is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain 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 plan is not required to cover Omeprazole/Sodium bicarbonate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Nexium DR 40 milligram tablets prescribed for gastroesophageal reflux disease. The Part D plan denied your request for a tiering exception because Nexium DR is a brand name Tier 3 drug and there is not a brand name drug for your condition in 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. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Nexium DR 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 a tiering exception request for Fetzima 80 milligram ER capsules prescribed for the enrollees condition. The Part D plan denied your 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.Fetzima 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 a tiering exception request for Albuterol Sulfate HFA 108 (90 base) microgram/actuation prescribed for the enrollees condition. The Part D plan denied your 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.Albuterol Sulfate HFA is 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 Benicar HCT 20-12.5 milligrams prescribed daily for hypertensive heart disease with heart failure. The Part D plan denied the 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 asked your prescriber to clarify your medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked to address the plans formulary alternatives. We received the documentation and included it in our review. There are no current medical records to support the prescribers statement. 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.A physician reviewed your appeal and determined that the plan is required to cover the Benicar HCT.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Ketoconazole 2% shampoo prescribed for the enrollees condition. The Part D plan denied your 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.Ketoconazole is a generic drug on Tier 2 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

You requested Ipratropium bromide .02 milligram/milliliter solution prescribed for chronic obstructive pulmonary disease. The Part D plan denied your request.We received the case to perform 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 Ipratropium bromide is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Ipratropium bromide. Please submit your request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets prescribed to treat chronic idiopathic constipation. The Part D plan denied your request. We received the case to perform 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 regulations and Medicare approved compendia. Medicare approved compendia does not support the use of the drug for your conditionA physician reviewed your appeal and determined that the plan is not required to cover Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Qtern 10 milligram/5 milligram tablets prescribed for the enrollees condition. The Part D plan denied your 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.Qtern 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 a tiering exception for Creon DR 12,000-38,000-60,000 unit delayed release capsules prescribed for pancreatic insufficiency. The Part D Plan denied your request. We received the case to perform 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.Creon DR is a biologic drug on Tier 3 of your plans formulary. There are no biologic drugs of the same type to treat your condition on the lower cost sharing tiers. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Creon DR at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Exforge 5-160-milligram tablet to treat hypertension. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 not provided patient specific clinical rationale, supported by medical records, as to 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 formulary coverage criteria is not supported.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Plaquenil 200 milligram tablets prescribed to treat rheumatoid arthritis. The Part D plan denied your request for a tiering exception.We received the case to perform 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 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.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 Lidocaine 5% ointment to treat the enrollees condition. The Part D plan denied the 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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Oxycontin 30 milligram tablets prescribed to treat pain. The Part D plan denied your request for a formulary exception. We received the case to perform 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 drug requested is not on the plans formulary. The medical records do not specifically address each formulary alternative and why they did not or would not work. A physician reviewed your appeal and determined that the plan is not required to cover Oxycontin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Xarelto 20 milligram tablets prescribed to treat the diagnoses of multiple pulmonary emboli and deep vein thrombosis. The Part D plan denied the request for a tiering exception.We received the case to perform 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.Xarelto is a brand drug on Tier 3 of the plans formulary. There are no brand names of the same type on the lower cost-sharing levels. In addition, the prescriber has not indicated why all alternatives required by the plan have not been tried and would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. 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 Jardiance 10 milligram tablets prescribed daily for type II diabetes mellitus with hyperglycemia. The Part D plan denied your request.We received the case to perform 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. Jardiance 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 of the plans formulary. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 20 milligram capsule to treat attention-deficit/hyperactivity disorder. The Part D plan denied the 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 not provided patient specific clinical rationale, supported by medical records, as to 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 formulary 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 Humira 40 milligram/0.8 milliliter injection pen prescribed as directed for pyoderma gangrenosum. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The record shows you were prescribed Humira injection pen as directed for pyoderma gangrenosum. 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 Humira injection pen because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Corlanor 5 milligram tablet prescribed twice daily for inappropriate sinus tachycardia. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia does 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.A physician reviewed your appeal and determined that the plan is not required to cover the Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Ajovy 225 milligram per 1.5 milliliter prefilled syringe prescribed for migraine prophylaxis. The Part D plan denied your request because the prior authorization requirements were not met.We received the case to perform 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 prescriber statement has been submitted at reconsideration that addresses one of the plans prior authorization requirements for coverage of Ajovy. However, no medical records have been submitted to validate this information. Therefore, it is not possible to determine with the submitted documentation if the plans requirements for coverage of this medication have been met. 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 coverage for Repatha 140 milligram per 1 milliliter subcutaneous injection pen prescribed for hyperlipidemia in an enrollee with clinical atherosclerotic cardiovascular disease. The Part D plan denied the request.We received the case to perform 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.Repatha is not included in the plans formulary. Praluent is on the plan's formulary. The prescriber has noted that the enrollee is intolerant of statins. However, the prescriber has not addressed why all other alternative medications that are included in the plans formulary to treat the noted condition 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 reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine 25 milligram suppository. The Part D plan denied your request.We received the case to perform 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 physician submitted a supporting statement. The prescriber statement indicates that Promethazine is prescribed to treat nausea and vomiting affecting pregnancy, antepartum. However, the Medicare approved compendia do not support the use of this specific drug for this specific condition. Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Promethazine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is tacrolimus 1 milligram prescribed three tablets twice daily for a history of liver transplant. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The record shows you received tacrolimus following your Medicare covered liver transplant on April 2, 2018. Therefore, the drugs are eligible for coverage under Medicare Part B and excluded from Part D coverage.This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Flector 1.3% patch to treat chronic pain due to osteoarthritis, rheumatoid arthritis, recent knee fracture, spinal stenosis, left hip replacement and lower back 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 diagnoses are off-label uses.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cortef 5-milllgram tablet treat the enrollees condition. The Part D plan denied the 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.At reconsideration a diagnosis 'supporting the metabolism of thyroid function' was given. No medical records were provided by the prescriber to support or clarify this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Our physician reviewer's opinion is that the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Favorable

You requested Sprycel 100 milligram tablets prescribed daily to treat chronic myeloid leukemia. The Part D plan denied your request.We received the case to perform 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 the physician prescribed Sprycel for an enrollee with Philadelphia chromosome positive chronic myeloid leukemia. The enrollee has chronic phase chronic myeloid leukemia and was previously treated with Gleevec, but experienced disease progression. The Medicare approved compendia support the use of the requested drug for the enrollees condition. In addition, the molecular testing results submitted at reconsideration show the enrollee does not have T315I/A, F317L/V/I/C, or V299L mutations. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Sprycel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 1.5 milligram capsule prescribed for your mood disorder and generalized anxiety disorder. 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 your diagnosis of mood disorder. 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. In addition, the documentation does not satisfy the plans coverage criteria. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.