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

At issue is Ventolin HFA inhaler 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.The prescriber has indicated that the alternatives required by the plan have not been tried and failed. Our physician reviewer's opinion is that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 200 milligram oral tablet to treat multiple sclerosis. The Part D Plan denied your request for a tiering exception. 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 information submitted at the reconsideration level. We asked your prescriber to send us information about your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why similar medications on the lower tiers would not work for you. However, we did not receive the documentation.Modafinil is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why other generics on lower tiers would not work for you. 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 Tadalafil 5 milligrams prescribed daily for bladder outlet symptoms and erectile dysfunction. 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. We also researched Medicare systems and reviewed the enrollment data available. The prescriber states the enrollee needs the medicine for the enrollees diagnoses. However, no medical documentation was submitted to support the enrollees diagnosis. We did not received sufficient information in the reconsideration request to obtain the information needed.A physician reviewed your appeal and determined that the plan is not required to cover the Tadalafil. There is insufficient documentation to determine if the medicine is medically necessary.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omega 3 Acid Ethyl Esters 1000 milligram prescribed for your hypertriglyceridemia. 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. The documentation supports the drug was prescribed for the enrollees diagnosis of hypertriglyceridemia. 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 reimbursement for the Onetouch Verio Flex System Kit with Device prescribed for monitoring your blood glucose levels. The Part D plan denied the appeal because glucose testing supplies are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. We received an auto forwarded 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.Glucose monitoring supplies are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Medicare Part D. As such, the Onetouch Verio Flex System Kit with Device is excluded from Part D coverage by Medicare law.We have determined that your plan is not required to reimburse you for the Onetouch Verio Flex System Kit with Device.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Premarin 0.625 tablets to treat an unknown diagnosis. The Part D plan auto-forwarded 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 use of the requested drug to treat an unknown diagnosis. The Medicare approved compendia do 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bepreve 1.5% eye drops prescribed as directed to treat allergic conjunctivitis. 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 records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover the Bepreve eye drops.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Restasis 0.05% eye drops prescribed for dry eye syndrome. 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. Restasis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand 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 Restasis at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cetirizine HCl 10 milligram tablets prescribed for allergic rhinitis. 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.We determined that the plan is not required to cover Cetirizine HCl because it was an over-the-counter drug. Nonprescription or over-the-counter drugs 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

You requested coverage for Entresto 24/26 milligram tablets prescribed for congestive heart failure with non-ischemic cardiomyopathy. 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. The documentation does not satisfy the plans prior authorization requirements. The submitted medical records do not support that all of the plans coverage criteria for 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

At issue is Quinine Sulfate 324 milligrams to treat ascites and leg cramps. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Nexium 40 milligram capsules prescribed for gastroesophageal reflux 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.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Perforomist 20 microgram/2 milliliter vial prescribed for unknown diagnosis. The Part D plan denied your request.We received a 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 Perforomist 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 Perforomist. Please consider submitting this 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

At issue is a tiering exception request for Dayvigo 5-milligram tablet to treat the enrollees insomnia. 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.Dayvigo 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 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

You requested Combipatch 0.05-0.14 milligram/day patches prescribed as directed for asymptomatic menopausal state. 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 Combipatch to treat your asymptomatic menopausal state. However, the Medicare approved compendia do not support the use of this drug for your conditions. 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 Combipatch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eliquis 5 milligram tablets prescribed twice daily for anticoagulation in the face of 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. There are no brand drugs of the same type on the lower cost sharing tiers. 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 for Chlordiazepoxide HCL 10 milligram capsules prescribed to treat the enrollees condition. 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.Chlordiazepoxide HCL is a generic drug on Tier 4 of the plans formulary. 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. Therefore, this drug is not eligible for a tiering exception.Your provider did not provide documentation of your office visit notes, what alternatives have been tried and why they are not effective. Our physician reviewer's opinion is that tiering exception criteria are not met
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate HCL 5 milligram tablets prescribed to treat the diagnosis of multiple sclerosis with other abnormalities of gait and mobility. 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.At reconsideration an additional diagnosis of multiple sclerosis related fatigue was added. The use of the requested drug to treat the provided diagnoses 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 your conditions. 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 Methylphenidate HCL 5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Botox 100 units/milliliter prescribed for Hailey-Hailey 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 records show you prescribed Botox 100 units/milliliter to treat the enrollees Hailey-Hailey disease. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Botox 100 units/milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eliquis 5 milligram tablets prescribed as directed for 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. There are no brand drugs of the same type on the lower cost sharing tiers. 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 Entresto 97-103 milligram oral tablets prescribed as directed. 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. Entresto 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 Kineret Solution Prefilled Syringe 100 milligrams/0.67 milliliter to treat pyoderma gangrenosum. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 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 this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 Taladafil 5 milligram tablets prescribed for erectile dysfunction. The Part D plan denied your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is not required to cover Taladafil. According to your plans Evidence of Coverage, drugs prescribed to treat sexual/erectile dysfunction are excluded from coverage under Medicare Part D. 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 Cyanocobalamin 1000 milligram per milliliter prescribed for vitamin B12 deficiency. The Part D plan denied your request. 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 Cyanocobalamin because prescription vitamin and mineral products 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 a tiering exception request for Albuterol Sulfate HFA 90 microgram Inhaler to treat asthma. 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.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 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

You requested Risedronate Sodium 150 milligram oral tablet. The Part D plan denied your request because the requested drug was prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.Your medical records show your doctor prescribed Risedronate Sodium to treat osteopenia of multiple sites. However, the Medicare approved compendia do not support the use of this drug for your condition. As such, the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Risedronate Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Creon 24,000-76,000-120,000 units six times daily to treat pancreatic insufficiency.   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.Creon 24,000-76,000-120,000 units is a biologic drug on Tier 3 of the plans formulary. There are no biologic 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 Stelara 45 milligrams per 0.5 milliliters syringe 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.Stelara 45 milligrams per 0.5 milliliters syringe 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 Stelara 45 milligrams per 0.5 milliliters syringe.