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

At issue is Synthroid 112 micrograms prescribed daily for hypothyroidism. The Part D Plan denied your request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. The case file was not submitted. There is insufficient documentation to verify if prior auuthorization requirements are met.A physician reviewed your appeal and determined that the plan is not required to grant your request.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Simponi to treat Crohns disease. The Part D plan denied the request. We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. 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 the enrollees 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 Simponi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq Extended Release 50 milligram tablet prescribed for nocturia. The Part D plan denied your request for a tiering exception because there are no lower tier alternatives of the same type for your condition. 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. There is no brand drug on a lower eligible tier of the same type that is used to treat your condition. Therefore, your plan is not required to offer you a lower cost share.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carbidopa-Levodopa-Entacapone 25 milligram-100 milligram-200 milligram tablet prescribed for Parkinsons disease. 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 also researched Medicare law and the plans rules.The documentation in the record shows that Carbidopa-Levodopa-Entacapone tablet is covered for the enrollee through a formulary exception. Medicare law and plan rules do not allow tiering exceptions for non-formulary drugs being covered through a formulary exception. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover a tiering exception for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Skyrizi 150 milligram dose kit 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan would likely cause harm or not be as effective as the requested drug.  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 Pentazocine-Naloxone Hydrochloride, 50/.05 milligram tablets prescribed for the management of chronic back pain due to post-laminectomy syndrome. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Pentazocine-Naloxone Hydrochloride as an off-formulary exception.The Medicare approved compendia support the use of the requested drug for the enrollees condition. However, the submitted medical records do not sufficiently address why the all of the alternative drugs that are already included in the plans formulary to treat the enrollees condition have not been tried, or are contraindicated. Therefore, the plan will not cover the Pentazocine-Naloxone Hydrochloride as an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atropine Sulfate 1% solution to treat neovascular glaucoma with increased intraoccular pressure. 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 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 Oxycodone Hydrochloride ER 80 milligram  prescribed for chronic pain syndrome. 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. 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 Oxycodone Hydrochloride ER 80 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tadalfil 20 milligrams prescribed for twice a day for failing Fontan physiology in an enrollee with normal pulmonary vascular resistance.    The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization requirements be met 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 information submitted at the reconsideration level. Your medical records show your doctor prescribed Tadalfil to treat failing Fontan physiology in an enrollee with normal pulmonary vascular resistance.  The prescriber was asked on 2/2/2021 if the enrollee has pulmonary artery hypertension and the prescriber responded, Other.  As well, in the Reconsideration appeal the prescriber stated that the enrollee was NYHA-III, WHO-FC III.  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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amitiza 24 microgram capsules prescribed for constipation. 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. The prescriber statement shows the enrollee has failed treatment with one alternative drug from the plans formulary. However, 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 Amitiza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate Hydrochloride 5 milligrams tablet prescribed for major depressive disorder, recurrent mild. The Part D plan denied a request for this drug because you did not have a medically accepted indication. We received a reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The physician submitted a supporting statement. The prescriber statement indicates that Methylphenidate Hydrochloride is prescribed for depression.The use of the requested drug to treat major depressive disorder is an off-label use. The Medicare approved compendia do not support the use of the requested drug. Medical records have not been submitted for review. Therefore, the documentation available 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 Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin ER, 80 milligram tablets prescribed for the management of chronic pain syndrome. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Oxycontin ER as an off-formulary exception.The submitted medical records show that Oxycontin ER has been prescribed to treat the enrollees chronic pain syndrome due to bilateral hip avascular necrosis. The Medicare approved compendia support the use of the requested drug for this condition. However, the submitted documentation does not sufficiently address why the drugs that are already included in the plans formulary to treat the enrollees condition have not been tried, or are contraindicated. Therefore, the plan will not cover the Oxycontin ER as an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate 500 mg to treat autoimmune related interstitial lung disease.  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.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 the enrollees condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5 milligram tablets to treat benign prostatic hypertrophy.   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 has not indicated why all alternatives required by the plan would likely cause harm or not be as effective as the requested drug.  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 Entyvio prescribed for Crohns disease. 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. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other biologics on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Entyvio.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levalbuterol Tartrate 45 microgram aerosol to treat chronic cough.  We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. A physician reviewed your appeal and determined that the plan is not required to cover the Levalbuterol Tartrate. 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 the enrollees 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 Nexletol 180 mg to treat hyperlipidemia. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted.Nexletol 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

At issue is Budesonide 1 milligram/2 milliliter to treat lichen planus of the esophagus. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted.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 the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch to treat low back pain and knee pain. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted.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 the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fycompa 6 mg tablet to treat a seizure disorder. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. The plan limits the amount of Fycompa to 30 tablets. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the enrollees condition or would be likely to cause harm to the enrollee. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Restasis 0.05% ophthalmic solution 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.Restasis 0.05% ophthalmic solution 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

At issue is Xifaxan 200 milligram tablet to treat pouchitis. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin 60 milligrams to treat chronic back pain. The Part D plan denied the request. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted.The enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan would likely cause harm or not be as effective for the enrollee as the requested drug. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otrexup 10 milligrams prescribed weekly for rheumatoid arthritis. 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 available. A physician reviewed your appeal and determined that the plan is not required to cover the Otrexup.As outlined in the Medicare approved compendia, a medically acceptable indication for the use of Otrexup is severe rheumatoid arthritis in patients with an insufficient response or intolerance to first-line therapy, including full-dose nonsteroidal anti-inflammatory drugs. While the submitted medical records support that the enrollee is being treated for rheumatoid arthritis, there is insufficient documentation to determine if the enrollee has had an insufficient response or intolerance to first-line therapy, including full-dose nonsteroidal anti-inflammatory drugs. Therefore, it is not possible to determine if the medication is being prescribed for a medically accepted indication, as outlined in the Medicare approved compendia. As such, the requested drug does not meet the definition of a Medicare Part D drug and is therefore not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitriol 0.5 microgram prescribed daily for post renal transplant. The Part D Plan denied the request because the prescriber did not provide the detailed information necessary to cover this drug for a prior authorization. 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 drug is eligible for Part B coverage. The beneficiary had a Medicare-covered transplant on February 13, 2021. Therefore, the drug can be considered for payment under the Part B benefit.A physician reviewed your appeal and determined that the plan is not required to cover.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humulin R 500 units/milliliter prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for a lower cost-sharing tier. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.Humulin R is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Suboxone film prescribed for the enrollees opioid dependence. 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 reviewed your appeal carefully. We reviewed all documentation available. The documentation supports the drug was prescribed for the enrollees diagnosis of opioid dependence. However, The prescriber has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.