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

At issue is Ursodiol 500 milligram tablet prescribed twice daily for cholestatic hepatitis. 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 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.Ursodiol 500 milligram tablet is a generic drug on Tier 4 of the plans formulary. Ursodiol has a unique mechanism of action, and 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 Copaxone (Glatiramer Acetate) 40 milligrams/milliliter prescribed for Multiple Sclerosis. Your Part D plan denied the appeal because Copaxone is a Specialty Tier 5 drug and is not eligible for a cost-share tiering 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 records submitted at the reconsideration level. The record shows your doctor prescribed Copaxone to treat your Multiple Sclerosis. Your plans formulary shows that Copaxone is a Tier 5, Specialty Tier drug. Medicare does not allow a cost-sharing tiering exception for a Specialty Tier drug.A physician reviewed your appeal and determined that the plan is not required to cover Copaxone because a Specialty Tier drug is not eligible for a cost-share tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 2.5 milligram tablets prescribed as directed for an enrollee with a history of bilateral pulmonary emboli. 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. Eliquis is a brand drug on Tier 2 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 Cyanocobalamin 1000 microgram/milliliter solution prescribed for pernicious anemia. The Part D plan denied your request because drugs prescribed for prescription vitamins and mineral products do not meet the definition of Part D drugs. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Cyanocobalamin because it was a prescription vitamin or mineral product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations 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 Dexilant DR capsules 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 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.Dexilant DR 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

You requested Tadalafil 5 milligram tablets prescribed daily for erectile dysfunction. The Part D plan denied your request because Medicare has excluded Part D coverage for the treatment of erectile dysfunction. 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 initially provided the diagnosis of erectile dysfunction. In the reconsideration request the prescriber changed the diagnosis to overactive bladder. However, the Medicare approved compendia do not support the use of this drug for this condition. As such, an exceptions request based on medical necessity cannot be considered because 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 Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ensure enlive liquid prescribed as a dietary supplement. The plan denied the request because Medicare excludes over-the-counter drugs from Part D coverage. 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.According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover Ensure enlive liquid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anucort-hydrocortisone 25 milligram suppositories prescribed for an unknown diagnosis. The Part D plan denied your request because the suppositories have been approved by the Food and Drug Administration. 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 determined that the plan is not required to cover the Anucort. According to Medicare rules, Anucort has not been found by the Food and Drug Administration to be safe and effective; and the drug product label has not been approved. Therefore, the drug is excluded from coverage under Medicare Part D. 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: Favorable

You requested Amitiza 24 microgram tablets prescribed twice daily for constipation. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request.  We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Amitiza 24 microgram tablets twice daily to treat your constipation. Slow transit constipation is a subset of idiopathic constipation and is supported by medical records submitted. The Medicare approved compendia do support the use of this drug for your condition. Therefore, the drug can be paid under the Part D benefit.  A physician reviewed your appeal and determined  that the plan is required to cover Amitiza 24 microgram tablets because it was prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Mycophenolate Mofetil, 500 milligram tablets. The Part D plan denied the request stating that the medication was prescribed for a non-medically accepted indication. 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. The records support that the Mycophenolate Mofetil has been prescribed to treat the following conditions: paraneoplastic autonomic neuropathy, myopathy, autoimmune dysautonomia, and sensory ganglionopathy with neuropathic pain. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted 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 the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Gammaplex, 20 grams per 200 milliliter intravenous solution. The Part D plan denied the request stating that the medication was prescribed for a non-medically accepted indication. 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. The records support that the Gammaplex has been prescribed to treat Hashimoto's autoimmune encephalitis. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted 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 Gammaplex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira 40 milligrams pen injection kit. The Part D plan denied a request for this drug because you did not have a medically accepted indication and prior authorization criteria were not met. 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 the enrollee has rheumatoid arthritis. The Medicare approved compendium does support the use of the requested drug. Also, the records show that the enrollee is off of Methotrexate 15 milligrams weekly, due to gastrointestinal symptoms and is well controlled/stable on Sulfasalazine. However, the documentation available does not show that the plan's step therapy coverage criteria has been satisfied.A physician reviewed your appeal and determined that the plan is not required to cover Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Multaq (Dronedarone Hydrochloride) 400 milligram tablets prescribed for atrial fibrillation and paroxysmal supraventricular tachycardia. You asked the Part D plan to provide a tiering 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. We also researched Medicare systems and reviewed the enrollment data available.The records show Multaq is being prescribed for atrial fibrillation and paroxysmal supraventricular tachycardia. The Medicare approved compendia support the use of the requested drug for your condition. Multaq is a brand name drug that is on Tier 3 on your plan's formulary. Your doctor submitted a prescriber statement indicating that you tried Bystolic, Metoprolol, Cartia, and Amiodarone. These drugs did not control your condition. However, the plan formulary includes other drugs on lower tiers that could be used to treat your condition. Your medical records do not show all alternative drugs on the plan formulary have been tried or why you cannot take them. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit. Therefore, the plan is not required to grant a tiering exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent patch prescribed for rheumatoid and osteoarthritis of multiple joints. 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 Lidocaine 5 percent patch for rheumatoid and osteoarthritis of multiple joints.In review of the Medicare approved compendia, rheumatoid and osteoarthritis of multiple joints is not a medically accepted indication for Lidocaine 5 percent patch as prescribed. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Lidocaine 5 percent patch  at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Silodosin 4 milligram capsules. The Part D plan denied the request initially stating that the documentation did not support an off-formulary exception. The plan then denied the request at redetermination stating that the drug was being prescribed for a non-medically accepted indication. 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. The records show that the Silodosin is being prescribed to treat incomplete bladder emptying in a female. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted 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 the Silodosin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vemlidy 25 milligram tablet prescribed once daily for liver transplant status. The Part D plan denied your request because the diagnosis provided does not meet the requirements of a Food and Drug Administration 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. Your medical records show your doctor prescribed Vemlidy to treat your liver transplant status. However, the Medicare approved compendium does not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Vemlidy because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Northera 100 milligram capsule to be given three times a day for neurogenic orthostatic hypotension. The Part D plan denied the drug. 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.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 received the prescriber statement and included it in our review. However, there were no medical records submitted. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Northera.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Myrbetriq 24 milligram ER tablets prescribed daily for an overactive bladder. 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.Myrbetriq 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: Favorable

At issue is Oxycontin 60 milligram tablets prescribed twice daily for chronic low back pain. 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 asked your prescriber to send us additional information about the enrollees condition. We received the documentation and included it in our review.The physician submitted a supporting statement and medical records. The documentation shows the physician had prescribed Oxycontin to treat chronic low back pain related to avascular necrosis of the hips following radiation therapy for liver and colon cancers. The Medicare approved compendium supports the use of the requested drug for the enrollees condition.The medical records show the enrollee has been taking Oxycontin since 2012. The prescriber statement and medical records show that the enrollee cannot take other drugs on the plans formulary for their condition. Specifically, the enrollees pain was not controlled with Xtampza ER.A physician reviewed your appeal and determined that the plan is required to cover Oxycontin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Panzyga 10 grams/100 milliliters to treat autonomic and small fiber neuropathy. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request.  We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Panzyga 10 grams/100 milliliters to treat your autonomic and small fiber neuropathy. 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 Panzyga 10 grams/100 milliliters because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Chlordiazepoxide Hydrochloride 5 milligram capsules prescribed for gastroesophageal reflux disease and abdominal pain. The Part D plan denied your request for a formulary exception because the drug was not 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. The documentation shows the Chlordiazepoxide Hydrochloride was prescribed for gastroesophageal reflux disease and abdominal pain. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Chlordiazepoxide Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gleostine 10 milligram capsules prescribed for the treatment of cancer. The Part D plan denied your request because the drug was excluded from coverage under Medicare Part D because it is a brand drug, and its manufacturer has not signed the Medicare Coverage Gap Discount Agreement. 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. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the list, the manufacturer, NextSource biotechnology, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Gleostine. 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 Ambrisentan 10 milligram tablet daily for digital ischemia secondary to scleroderma. The Part D plan denied the drug because it was not medically necessary. 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.Ambrisentan is being requested to treat digital ischemia secondary to scleroderma. The Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover the Ambrisentan.