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

You requested Leflunomide 10 milligram tablets prescribed daily for Arthropathic psoriasis, unspecified. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Leflunomide is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is 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

You doctor requested coverage for Osphena 60 milligram tablets prescribed for asymptomatic menopausal state and asymptomatic post procedural ovarian failure. The Part D plan denied the request stating the medication was being prescribed for non-covered conditions.  We received the case to perform 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 submitted by you at reconsideration states that you take Osphena due to vaginal dryness and irritation caused by wearing a vaginal pessary ring due to your prolapsed bladder. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of any of the noted conditions. During this review, we requested a statement and supporting medical records from you doctor to clarify what the Osphena is being prescribed for. Your doctor did not respond to our request for information. Therefore, the available documentation supports that the drug is being prescribed for non-medically accepted indications and 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 Osphena.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Enemeez Mini Enema prescribed to treat constipation. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The drug requested is available without a prescription. Over the counter medications do not meet the definition of a Part D drug. A physician reviewed your appeal and determined that the plan is not required to cover Enemeez Mini Enema.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Neupro 6 milligram patches prescribed every 24 hours for Parkinsons disease. The Part D plan denied your request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Neupro 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 of the plans formulary. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets prescribed three times daily for small intestine bacterial overgrowth, abdominal bloating, intestinal metaplasia of gastric cardia, and lymphocytic colitis. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. At initial determination and redetermination the diagnoses of small intestine bacterial overgrowth, abdominal bloating, intestinal metaplasia of gastric cardia, and lymphocytic colitis were given. At reconsideration a diagnosis of irritable bowel syndrome with diarrhea was given. No medical records were provided by the prescriber to support this diagnosis change. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zenatane 40-milligram tablet to treat acne. The Part D plan denied the request. The requested drug is not on the plans formulary. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to 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 formulary 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 Restasis 0.05 percent eye solution prescribed daily for keratoconjunctivitis sicca. The Part D plan denied your request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Restasis 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 of the plans formulary. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Amphetamine/Dextroamphetamine ER 30 milligram extended release 24-hour capsules. The Part D plan denied your request.  We received the case to perform an independent and de novo review. To make our decision, we read 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 indicates that Amphetamine/Dextroamphetamine ER has been prescribed for idiopathic central nervous system hypersomnia. However, 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 drug is being prescribed for a non-medically accepted indication and 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 Amphetamine/Dextroamphetamine ER capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 600 micrograms per 2.4 milliliter pen prescribed once daily for osteoporosis. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria. The plan allows a total of 24 months of therapy with parathyroid hormone analogs, such as Forteo, for a lifetime. The medical records provided document several different start dates for this drug. Therefore, it is unable to be determined if the enrollee has exceeded the maximum dose of 24 months of therapy in a lifetime. A physician reviewed your appeal and determined that the plan is not required to cover Forteo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ritalin 5 milligram tablets. The Part D plan denied the request for coverage.  We received the case to perform 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 indicates that Ritalin has been prescribed for idiopathic hypersomnolence syndrome.  However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and 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 Ritalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The physician submitted a supporting statement. The prescriber statement indicates that Lidocaine 5% patch is prescribed to treat neuropathic pain with a diagnosis of disorder of the autonomic nervous system, unspecific. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s).A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Sumatriptan 6 milligrams per 0.5 milliliter injection prescribed to treat the diagnosis of migraine headaches. The Part D plan denied the request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Sumatriptan is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated why all alternatives required by the plan have not been tried and would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, this drug is not eligible for a tiering exception.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 Saxenda 3 milligram/0.5 milliliter pen injector prescribed daily for morbid obesity. The Part D plan denied your request because Medicare has excluded Part D coverage for drugs used to treat weight gain (promote weight loss). We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We determined that the plan is not required to cover Saxenda because drugs used to treat weight gain (promote weight loss) are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Omega 3 Acid Ethyl Esters 1 gram capsules prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because Omega 3 Acid Ethyl Esters is a generic Tier 3 drug and the lower cost-sharing tiers do not contain alternative drugs 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. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Omega 3 Acid Ethyl Esters is a generic Tier 3 drug. There are no alternate 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

You requested coverage for Repatha 140 milligram per 1 milliliter subcuataneous injection pen prescribed for hyperlipidemia. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Repatha is not included in the plans formulary. The prescriber has not sufficiently addressed why all alternative medications that are included in the plans formulary to treat the noted condition 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

At issue is Lidocaine 5% ointment prescribed to treat the diagnosis of chronic pain related to degenerative joint disease. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac sodium 3 percent gel prescribed as directed for primary generalized osteoarthritis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. 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 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 Diclofenac sodium 3 percent gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Eliquis 5 milligram tablets prescribed for atrial fibrillation. The Part D plan denied your request for a tiering exception because Eliquis is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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 plan shows Eliquis is a brand name Tier 3 drug. 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 Nucynta 50 milligram tablet every eight hours as needed to treat chronic pain syndrome. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The 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

You requested coverage for Guanfacine 1 milligram tablets prescribed daily for bipolar disorder, unspecified. 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 Guanfacine for bipolar disorder, unspecified. Your provider states that the enrollee is using the medication for inattention likely secondary to their bipolar disorder and they refuse anti-psychotics due to side effects.In review of the Medicare approved compendia, inattention likely secondary to bipolar disorder is not a medically accepted indication for Guanfacine. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Guanfacine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Denavir 1% Cream to treat herpes labialis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to 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 formulary coverage criteria is not supported.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 10 milligram tablets to treat the enrollees condition. The Part D plan denied your request for a formulary exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Ubrelvy is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Ubrelvy.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Librax (Chlordiazepoxide-Clidinium) 5 milligram/2.5 milligram oral capsule prescribed daily for irritable bowel syndrome. The Part D Plan denied your request because Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. 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 the Librax (Chlordiazepoxide-Clidinium) is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover Librax (Chlordiazepoxide-Clidinium). Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Myrbetriq ER 50 milligram tablets prescribed daily for urinary urge incontinence. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Myrbetriq ER 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 of the plans formulary. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clonazepam 1 milligram oral tablet prescribed four times daily for panic disorder. The Part D plan denied your request. 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. 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 amount of the medication. We did not receive the documentation requested.The records show Clonazepam was prescribed to treat panic disorder. The Medicare approved compendia do support the quantity of 1 milligram four times a day for this condition. However, there are no medical records to support the enrollee has a diagnosis of panic disorder or to support the enrollee has been assessed for risk versus benefit in using this High Risk Medication. Therefore, it cannot be determined if the drug was prescribed to treat a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Clonazepam.