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

You requested Hydroxyzine HCL 50 milligram tablets prescribed as needed for restless legs syndrome. 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. Your medical records show your doctor prescribed Hydroxyzine HCL to treat your restless legs syndrome. 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 Hydroxyzine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 1% gel prescribed for chronic knee pain. 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.The submitted documentation indicates your doctor prescribed Diclofenac Sodium gel for chronic knee pain. The Medicare approved compendia do not support the use of this drug for your condition. The documentation does not satisfy the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Saxenda 18 milligram/3 milliliter pen injector prescribed daily for abnormal weight gain. The Part D plan denied your request because Medicare has excluded Part D coverage for drugs used for the treatment of weight gain (promote weight loss) are excluded from coverage. 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 Saxenda because drugs used to treat weight gain (promote weight loss) are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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 Duragesic 25 microgram patches prescribed 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.Duragesic 25 microgram patch 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 Duragesic 25 microgram patches.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cinacalcet Hydrochloride 90 milligram oral tablet prescribed for secondary hyperparathyroidism of renal origin. 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 the physician ordered the Cinacalcet to be used while in dialysis. According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. We determined that the plan is not required to cover the Cinacalcet Hydrochloride. Drugs which are eligible for Part B coverage are excluded from Part D coverage.We determined that the plan is not required to cover the Cinacalcet Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Trelegy Ellipta 100-62.5-25 microgram inhaler prescribed for chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception because Trelegy Ellipta is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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 shows Trelegy Ellipta 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

You requested Modafinil 200 milligram tablets prescribed daily for other fatigue and sleep disorder unspecified. 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. Your medical records show your doctor prescribed Modafinil to treat your other fatigue and sleep disorder unspecified. 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 Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide EC 3 mg capsule.  At initial determination and redetermination the diagnosis of unspecified diarrhea was given. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read 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 of collagenous colitis was given. No medical records were provided by the prescriber to support this change of diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Probenecid 500 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 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.Probenecid a generic drug on Tier 3 of the plans formulary. A request was submitted to the prescriber for medical records to support that all lower tiered generic drugs to treat the condition have been tried and failed or why they would likely not be as effective as the requested drug.  A reply from the prescriber was not received. 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 Cinacalcet Hydrochloride 30 milligrams to treat hypercalcemia in renal transplant recipient. 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 Pregabalin 50 milligram capsules prescribed twice daily for chronic midline low back pain without sciatica and chronic pain of right hip. 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. Your medical records show your doctor prescribed Pregabalin to treat your chronic midline low back pain without sciatica and chronic pain of right hip. 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 Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Isotretinoin 10 milligram capsules prescribed for lichen planopilarlis. 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 Isotretinoin for lichen planopilarlis. In review of the Medicare approved compendia, lichen planopilarlis is not a medically accepted indication for Isotretinoin. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the drug at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Bumetanide 2 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the prescriber did not address all lower tiered drugs to treat your condition have been tried and failed or provided reasons why they would likely not be as effective as the requested drug. We received an auto-forward 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 Bumetanide is a generic Tier 3 drug on the plans formulary. We asked your doctor to send us supporting information. No additional documentation was received. There are no records submitted to support if all lower tiered drugs to treat your condition have been tried and failed or provided reasons why they would likely not be as effective as the requested drug.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Memantine Hydrochloride 5 milligram tablets prescribed for mild cognitive impairment. 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.The submitted documentation indicates your doctor prescribed Memantine Hydrochloride for mild cognitive impairment. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that the drug was 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 Diclofenac Epolamine 1.3% patch to treat the diagnosis of acute pain due to fracture of the thoracic spine. The Part D plan denied your request stating that the provided diagnosis is a non-medically accepted indication and the requested drug was not on the plans formulary.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.Diclofenac Epolamine 1.3% patch is not on the plans formulary. 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 conditions.  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 Ingrezza 40 milligram oral capsule prescribed for tardive dyskinesia. 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. 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 Tramadol extended release 24 hour 100 milligram tablets prescribed 4 times a day to treat pain during movement. 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. We also researched Medicare regulations and Medicare approved compendia. The plan limits the coverage of this drug to 300 milligram tablets per day as the Food and Drug Administration indicates the maximum amount per day to be given is 300 milligrams. The prescriber has not submitted documentation as to why the amount over the quantity limit was required or that higher strength formulary alternatives were tried or clinically inappropriate.  DrugDex, a Medicare approved compendia states:  '2) Titration: Increase by 100 mg increments every 5 days as necessary, to a maximum dosage of 300 mg/day [15][16]  15. Product Information: CONZIP(R) oral extended-release capsules, tramadol HCl oral extended-release capsules. Vertical Pharmaceuticals LLC (per FDA), Bridgewater, NJ, 2019.  16. Product Information: Tramadol hydrochloride oral extended-release tablets, tramadol hydrochloride oral extended-release tablets. Aurobindo Pharma USA, Inc (per DailyMed), East Windsor, NJ, 2019.'    A physician reviewed your appeal and determined that the plan is not required to cover 100 milligram extended release tablets of Tramadol prescribed 4 times of day.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Triazolam 0.25 milligram tablets to treat the diagnosis of insomnia. 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.Triazolam 0.25 milligram tablets 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 Triazolam 0.25 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eliquis 5 milligram tablets prescribed as directed for paroxysmal atrial fibrillation. The Part D plan denied your 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. Eliquis is a brand drug on Tier 3 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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 this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trintellix 20 milligram tablet to treat major depressive disorder.   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.Trintellix 20 milligram 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 a request for coverage of Zolpidem Tartrate 10 milligram tablets prescribed for insomnia. The Part D plan denied the request for coverage.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 documentation does not satisfy the plans coverage criteria. The prescriber has addressed the prior authorization criteria; however, the responses do not satisfy all of the plans requirements for coverage of this medication. 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 Acthar 80 units/milliliter injection gel prescribed as directed for other rheumatoid arthritis unspecified, and other osteoporosis without current pathological fracture. 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. Your medical records show your doctor prescribed Acthar to treat rheumatoid arthritis as chronic use. However, the Medicare approved compendia do not support the use of this drug for your condition. The documentation does not satisfy the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexium DR 40 milligram capsules to treat gastroesophageal reflux disease. 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.Nexium DR 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 Nexium DR 40 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick, 140 milligram/milliliter auto-injector prescribed to treat  to treat mixed hyperlipidemia in an enrollee with clinical atherosclerotic cardiovascular disease.   The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/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

At issue is Otezla 30 milligrams twice a day to treat moderate to severe plaque psoriasis. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation supports the drug was prescribed for your condition. However, the plan's prior authorization coverage criteria has not been met. There is no evidence that Enbrel and Humira have been tried and failed nor does the Medicare approved compendia support these drugs are contraindicated due to your comorbidities.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.