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

At issue is a tiering exception for Entresto 97 milligram/103 milligram tablet prescribed for acute on chronic combined systolic and diastolic heart failure. The Part D Plan denied your request stating that the drug is already being provided at the lowest cost-share amount allowed. 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.Entresto 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. Therefore, this drug is not eligible for a tiering exception.Our Physician Reviewers opinion is that the plan is not required to cover Entresto at a lower tier cost.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Letrozole 2.5 milligram tablets prescribed as directed for breast cancer. The Part D Plan denied your request for a tiering exception because there were no 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.Letrozole is a generic drug on Tier 2 of the plans formulary. There are no drugs of the same type on the lower cost sharing tiers to treat the enrollees 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 grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% Patch, 60 patches per 2 days, to treat lower back pain associated with osteoarthritis.   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 Plan limits the amount of Lidocaine 5% patch to 90 patches per 30 days. The prescriber has indicated that a clerical error incorrectly requested 60 films for two days, rather than 60 films for thirty days.  Although noted in this review, this information shoulder be provided to the Plan as the initial determination was made based on the request for two day.  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 Omnipod dash 5 pack pods prescribed as directed to treat diabetes mellitus. 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 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.Omnipod dash 5 pack pods is a brand drug on Tier 3 of the plans formulary. There are no brand drugs (insulin delivery pumps) of the same type on the lower cost sharing tiers. Therefore, this drug (pump) 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 Farxiga 10 milligrams tablets to treat type 2 diabetes. The Part D plan denied your request for a non-formulary exception. The case was auto-forwarded.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. 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. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz 5 milligram tablets prescribed twice daily for dermatomyositis. The Part D plan denied your request 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 medical records show the doctor prescribed Xeljanz for dermatomyositis. 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 Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide-Formoterol Fumarate 160-4.5 micrograms/actuation in aerosol prescribed for asthma. The plan denied the appeal because this drug is not listed on your formulary plan (non-formulary). 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 show your doctor prescribed Budesonide-Formoterol Fumarate 160-4.5 micrograms/actuation in aerosol for your asthma. This drug is not listed in your plans formulary for your condition. Your doctor did not indicate that you tried drugs listed on your plans formulary for your condition and why they would not work as well or that they caused adverse effects. Therefore, the requested drug cannot receive a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Budesonide-Formoterol Fumarate 160-4.5 micrograms/actuation in aerosol because the documentation does not show that you have met the coverage criteria for a formulary exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Ongentys 50 milligram capsules. The Part D plan denied your request because the medication was not included on the plans formulary and the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation supports that Ongentys has been prescribed in the management of the enrollees Parkinsons disease. However, the prescriber has not sufficiently addressed why all alternatives required by the plan to treat this condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a quantity limit exception for Cimzia 400 milligram/2 milliliter Syringe Kit with a quantity of 2 syringe kits per 56 days to treat ankylosing spondylitis. The Part D plan indicated the drug is approved but not for the amount requested. We received a reconsideration request from the plan. 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 plans coverage rules indicate that Cimzia 200 milligram/2 milliliter Syringe Kit is covered for 1 kit per 28 days. The request for 2 syringe kits exceeds the plans quantity limit. The prescriber has not submitted supporting evidence of why more than the covered amount of the drug is required or that the amount allowed was not effective. Therefore, a quantity limit exception cannot be made.  Our physician reviewers opinion is that the plan is not required to cover 2 syringe kits of Cimzia 400 milligram/2 milliliters.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzapine Hydrochloride 10 milligrams prescribed twice a day to treat muscle spasms associated with a non-acute pain condition. 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 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.  Also, the documentation provided does not show the enrollee has satisfied the plans coverage criteria.  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

At issue is Cyclophosphamide 25 milligram capsules prescribed for treatment of sarcoma of the uterus. 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. Medicare rules state that drugs taken orally during cancer chemotherapy provided they have the same active ingredients, and are used for the same indications as chemotherapy drugs that would be covered if they were not self-administered, are covered under Part B. Part D excludes any drug for which payment would be available under Medicare Part A or Part B for that individual. The record shows the drug was prescribed to be used as an orally administered chemotherapy agent. We determined the Part D plan is not required to cover Cyclophosphamide. 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 Diovan 160 milligram tablets prescribed daily for hypertension. The Part D plan denied your request for a tiering exception. 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. The requested drug is being provided by your plan under a formulary exception. Diovan 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.A physician reviewed your appeal and determined that non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Viibryd 20 milligrams tablets. 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 documentation shows Viibryd was prescribed to treat anxiety and insomnia. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to cover Viibryd.
Appeal type: Prescription Drug
Decision: Favorable

You requested Nuedexta Capsule 20-10 milligrams prescribed for pseudobulbar affect. The Part D plan denied your request because the diagnoses provided did not meet the requirements of Food and Drug Administration medically accepted indications. 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 Nuedexta to treat your pseudobulbar affect. The Medicare approved compendia support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is required to cover Nuedexta because your diagnosis does meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron 4 milligram tablet prescribed as directed for nausea related to heartburn, geographic tongue, and aphasia following a cerebral infarction. 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. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Ondansetron to treat your condition. 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 Ondansetron.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xalatan 0.005% Solution to be given in both eyes every night. 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 regulations and Medicare approved compendia. The records do not contain any diagnosis. There is insufficient documentation to determine if the drug is being used for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our Physician Reviewers opinion is that the plan is not required to cover Xalatan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is ZTlido Topical Patch 1.8% prescribed for post herpetic nervous system involvement. The plan denied the request because the provider has not demonstrated why it is medically necessary to make an exception. We received an auto forward 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 show your doctor prescribed ZTlido Topical Patch for your post herpetic nervous system involvement. This drug is not listed in your plans formulary for your condition. The documentation submitted is insufficient to determine the medical reasons why the alternative drugs on the plans formulary would not work as well for you, and/or that they caused adverse effects or may be harmful. Therefore, the requested drug cannot receive a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover ZTlido Topical Patch because the documentation does not show that you have met the coverage criteria for a formulary exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Corlanor 7.5 milligram tablets prescribed twice daily for inappropriate sinus tachycardia. The Part D plan denied your request because the provided diagnosis 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 Corlanor 7.5 milligram tablets to treat your inappropriate sinus tachycardia. 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 Corlanor because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stiolto Respimat 2.2-2.5 microgram mist inhaler prescribed for chronic obstructive pulmonary disease. 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. Stiolto Respimat 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. 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 Eliquis 5 milligram tablets prescribed daily for atrial fibrillation. The Part D plan denied your request for a tiering exception. 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. The requested drug is being provided by your plan under a formulary exception. Eliquis 5 milligram tablets are 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. 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 Loteprednol Etabonate 0.5% ophthalmic solution ordered three times daily for infectious iridocyclitis. The Part D plan approved the drug as a non-formulary exception but denied the tiering exception request. 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.Loteprednol Etabonate 0.5% ophthalmic solution is a generic drug not on the plans formulary. This 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 Xeljanz 5 milligram tablets prescribed twice daily for alopecia areata. The Part D plan denied your request because the provided diagnosis 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 Xeljanz 5 milligram tablets to treat your alopecia areata. The use of the requested drug to treat the provided diagnosis is an off-label use. 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 Xeljanz because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zioptan PF 0.0015% eye drops prescribed daily for bilateral, mild stage, low-tension glaucoma. The Part D plan denied your request for a tiering exception because the drug you requested is not included on the plans formulary.  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 you were prescribed Zioptan PF eye drops to treat your condition. Since the drug isnt on the plans formulary, it is not eligible for a tiering exception. 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 Zioptan PF eye drops.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Vyvanse 30 milligram capsules. 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. The documentation supports that Vyvanse has been prescribed to treat the enrollees attention-deficit/hyperactivity disorder. However, Vyvanse is not included in the Part D plans formulary. The prescriber has not sufficiently addressed why all alternatives in the plans formulary to treat this condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Our physician reviewer's opinion is that formulary exception criteria are not met.