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

At issue is Latuda 80 milligram tablets prescribed for the diagnosis of Schizophrenia. The Part D plan denied your request for a tiering exception because the drug is already being provided at the lowest cost-share amount allowed by the plan. We received a standard 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 rules and the plans formulary.Latuda 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. 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 Latuda at a lower cost-sharing amount.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Bioidentical Hormone Replacement Therapy Heavy Cream 0.0025 milligram cream prescribed for menopause. The Part D plan denied your request because the drug at issue did not meet the definition of a Part D drug. 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 determined that the plan is not required to cover the drug because it is not a Food and Drug Administration approved drug. Drugs that are not Food and Drug Administration approved 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: Favorable

At issue is Vimpat 50 milligram tablet prescribed three times daily for partial symptomatic epilepsy with complex partial seizures. The Part D plan denied your request for a quantity limit exception because the records did not indicate why the dose could not be combined as Vimpat 150 milligram tablet once daily. 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 includes a progress noted dated October 11, 2019, which supports the enrollee has partial seizures and has been seizure free on a dose of Vimpat 75milligrams twice daily. Medicare drug compendia support Vimpat use as twice daily dosing for the condition of partial seizures.  Three 50 milligram tablets would be required to enable the dosing of 75 milligrams twice daily for a tablet that can be cut in half. The Part D plans formulary allows 60 tablets of Vimpat 50 milligrams every 30 days. This drug is eligible for a quantity limit exception.A physician reviewed your appeal and determined that the plan is required to cover 90 tablets for 30 days of Vimpat 50 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyzulta 0.024 percent eye solution prescribed as directed for open angle glaucoma. 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 also researched Medicare systems and reviewed the enrollment data available. Your physician submitted a supporting statement and medical records. The medical records show the physician had prescribed Vyzulta 0.024 percent eye solution to treat your open angle glaucoma. The Medicare approved compendia support the use of the requested drug for your condition.However, the drug requested is not on the plans formulary or their list of covered drugs. We cannot consider a tiering exception for a drug that is not listed on the plans formulary. A physician reviewed your appeal and determined that the plan is not required to cover Vyzulta 0.024 percent eye solution because a tiering exception cannot be allowed for an off-formulary drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Omega 3 acid ethyl esters 1 gram prescribed as directed for malignant neoplasm of the pleura. The Part D plan denied the request for a tiering 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 also researched Medicare systems and reviewed the enrollment data available.The record shows you were prescribed Omega 3 acid ethyl esters 1 gram as directed for malignant neoplasm of the pleura. However, the Medicare approved compendia do not support the use of this drug for your condition. The request for a tiering exception was not reviewed. We cannot consider a tiering exception for a drug that is not eligible for Part D coverage. 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 Omega 3 acid ethyl esters because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zioptan 0.0015 percent eye solution prescribed as directed for open angle glaucoma. 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 also researched Medicare systems and reviewed the enrollment data available. Your physician submitted a supporting statement and medical records. The medical records show the physician had prescribed Zioptan 0.0015 percent eye solution to treat your open angle glaucoma. The Medicare approved compendia support the use of the requested drug for your condition.However, the drug requested is not on the plans formulary or their list of covered drugs. We cannot consider a tiering exception for a drug that is not listed on the plans formulary. Therefore, the plan is not required to grant an off-formulary exception for the Zioptan 0.0015 percent eye solution. A physician reviewed your appeal and determined that the plan is not required to cover Zioptan 0.0015 percent eye solution because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Horizant Extended Release Tablet 600 milligrams prescribed daily for meralgia paresthetica. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received an expedited 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 Horizant Extended Release for meralgia paresthetica and an additional diagnosis of other and unspecified polyneuropathies. In review of the Medicare approved compendia, meralgia paresthetica and unspecified polyneuropathies are not medically accepted indications for Horizant Extended Release. 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

At issue is Methadone 5 milligram tablets prescribed 20 tablets per every 30 days for chronic shoulder pain. 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. We also researched Medicare regulations and reviewed the plans enrollment data available.The medical records show the doctor prescribed Methadone to treat chronic shoulder pain. The Medicare approved compendia support the use of this drug for this condition. However, the plan requires certain prior authorization criteria be met.  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 Methadone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Morphine Sulfate ER 20 mg capsule prescribed twice daily for chronic pain syndrome. The Part D Plan denied your request for a tiering exception because the drug is not on the plans formulary. 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.Morphine Sulfate ER 20 mg capsule is a non-formulary medication and has been approved by the Plan through the non-formulary coverage criteria.   Non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methotrexate 2.5 milligram tablets prescribed to take 1 per day to treat psoriasis. The Part D Plan denied your request for a tiering exception because there are no drugs in a lower Tier approved for treating the same condition that the requested Tier 3 drug is being used to treat. 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. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare rules and the plans formulary.Methotrexate 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. 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 Methotrexate at a lower cost-sharing amount.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Spravato 84 milligrams dose pack prescribed for major depressive disorder. 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 Spravato is being prescribed to the enrollee for treatment of depression. Medicare law specifically excludes coverage for any drug for which payment would be available under Medicare Parts A or B for that individual. Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner). Spravato is a type of drug that must be administered under direct observation of a health care provider and monitored for at least two hours after administration. The Food and Drug Administration has mandated a Risk Evaluation and Mitigation Strategy for Spravato. This strategy requires that Spravato be only dispensed and administered to patients in a medically supervised healthcare setting that monitors the enrollee. Therefore, the drug as administered is eligible for coverage under Medicare Part B. Drugs which are eligible for coverage under Part B are excluded from Part D coverage by Medicare law. No additional documentation was requested from the prescriber. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Spravato. 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

You requested Spravato 56 milligrams dose pack prescribed for major depressive disorder. 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 Spravato is being prescribed to the enrollee for treatment of depression. Medicare law specifically excludes coverage for any drug for which payment would be available under Medicare Parts A or B for that individual. Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner). Spravato is a type of drug that must be administered under direct observation of a health care provider and monitored for at least two hours after administration. The Food and Drug Administration has mandated a Risk Evaluation and Mitigation Strategy for Spravato. This strategy requires that Spravato be only dispensed and administered to patients in a medically supervised healthcare setting that monitors the enrollee. Therefore, the drug as administered is eligible for coverage under Medicare Part B. Drugs which are eligible for coverage under Part B are excluded from Part D coverage by Medicare law. No additional documentation was requested from the prescriber. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Spravato. 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 Ozempic 1 milligram injection prescribed for diabetes mellitus. 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.Ozempic 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 cover Ozempic at a lower cost-sharing tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide 1milligram/2 milliliters nebulizer solution prescribed as directed for COVID-19. The Part D plan denied your request because it does not meet the criteria of 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 also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Budesonide 1milligram/2 milliliters nebulizer solution to treat your COVID-19. 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 Budesonide 1milligram/2 milliliters nebulizer solution because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 49-51 milligram tablets prescribed twice daily for systolic heart dysfunction. The Part D plan denied your request for a tiering exception because there is no alternative brand name drugs for the enrollees condition in a lower cost-sharing tier. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Entresto 49-51 milligram tablet 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 cover Entresto 49-51 milligram tablets at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets prescribed 60 per 30 days to treat paroxysmal atrial fibrillation. The Part D Plan denied your request for a tiering exception because the drug is being provided at the lowest cost-sharing amount allowed by the plan. 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. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare rules and the plans formulary.Eliquis 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.A physician reviewed your appeal and determined that the plan is not required to cover Eliquis at a lower cost-sharing amount.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Kineret, 100 milligrams per 0.67 milliliter syringe, for the treatment of recurrent idiopathic pericarditis. The Part D plan denied your request because the drug was ordered for a non-medically accepted indication. 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. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records show your doctor prescribed Kineret for your recurrent idiopathic pericarditis. However, the Medicare approved compendia do 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 the Kineret.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Lupron 45 milligrams prescribed for prostate cancer. The Part D plan denied your request for a 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 also researched Medicare systems and reviewed the enrollment data available. The record shows Lupron is prescribed for prostate cancer. The Medicare approved compendia supports the use of the requested drug for your condition. The plan shows Lupron is a brand name Tier 2 drug on your formulary. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Enoxaparin, 80 milligrams per 0.8 milliliters syringe, prescribed for anticoagulation therapy due to your atrial fibrillation and history of cerebrovascular accident. The Part D Plan denied your request for a tiering exception because  the submitted documentation did not explain why the plans alternative drug(s) in a lower tier would not work just as well. 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 Enoxaparin is not eligible for a tiering exception.Enoxaparin  is a generic drug on Tier 4 of the plans formulary. Your doctor submitted a supporting statement and medical records. The submitted documentation shows that you could not tolerate Eliquis or Xarelto due to dizziness and low platelet counts. However, the plans formulary includes Heparin Sodium, which is the same class as Enoxaparin but on a lower cost tier of your plans formulary. Your doctor did not address why the Heparin Sodium would not work for you. Therefore, the record does not support that all generic drugs on lower tiers have been tried, and the plan is not required to cover the Enoxaparin at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligrams prescribed daily for irritable bowel syndrome with diarrhea and small bowel bacterial overgrowth syndrome. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received an expedited 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 Xifaxan for irritable bowel syndrome with diarrhea and small bowel bacterial overgrowth syndrome. The Medicare approved compendia does not support that your condition is a medically accepted indication for Xifaxan. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Xifaxan at issue.