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

At issue is Retacrit 4,000 per milliliters to treat an unspecified diagnosis. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for the prescribers statement, completion of the prior authorization questionnaire, and documentation to show why the requested drug was needed. However, we did not receive the requested documentation. The documentation is insufficient to support the plan's coverage criteria were met 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 Dupixent 300 milligram/2 milliliter subcutaneous injections prescribed as directed for atopic dermatitis. The Part D plan denied coverage because the prior authorization criteria were not met. 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. The medical records show the doctor prescribed Dupixent to treat atopic dermatitis. The Medicare approved compendia do support the use of this drug for the enrollees condition. The plan requires an intolerance or contraindication to a topical calcineurin inhibitor drug before they will cover the requested drug. 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 Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine 10 milligrams prescribed two times daily for muscle spasm. The Part D plan denied the 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. The record shows you were prescribed Cyclobenzaprine 10 milligrams two times daily for other muscle spasms. 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 the Cyclobenzaprine because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sensipar 30 milligrams for hyperparathyroidism and hypercalcemia. 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 submitted documentation indicates your doctor prescribed the drug for hyperparathyroidism, unspecified, and hypercalcemia.  It is documented you have chronic kidney disease; however, it is not documented that you are on dialysis. The Medicare approved compendia do not support the use of this drug for your conditions. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover Sensipar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entacapone, 200 milligram tablets prescribed for Parkinsons disease. The Part D Plan denied your request for a tiering exception because the submitted documentation did not explain why the plans alternative drugs in lower tiers would not work just as well. 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. A physician reviewed your appeal and determined that the Entacapone is not eligible for a tiering exception.Entacapone is a generic drug on Tier 3 of the plans formulary. The submitted documentation does not address why the generic drugs of the same type on the lower tiers of the plans formulary have been tried and failed, or are contraindicated. Therefore, the plan cannot grant a tiering exception for the Entacapone at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch to treat pain due to a compression fracture of the L1 lumbar vertebra.  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

You requested Adderall extended-release 30 milligram tablets prescribed daily for obstructive sleep apnea. The Part D plan denied your request because 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 Adderall was prescribed to treat obstructive sleep apnea and hypersomnia. 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 Adderall extended-release 30 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xolair 150 milligrams per milliliter, 375 milligrams to be given subcutaneous every four weeks for allergic asthma. The Part D plan denied the drug because the prior approval criteria were not met. 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 records submitted at the reconsideration level.The details below are written in medical language. If you have questions, please contact your provider.The prescriber submitted a statement and medical records. The plan requires a baseline serum total immunoglobulin E level greater than or equal to 30 international units/milliliter and less than or equal to 700 international units/milliliter for patients 12 years of age and older and a positive skin test or in vitro reactivity to a perennial aeroallergen before they will cover the requested drug. 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 Xolair.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zypitamag, 4 milligram tablets prescribed for the treatment of pure hypercholesterolemia and atherosclerotic heart disease of native coronary artery without angina. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Zypitamag as an off-formulary exception.The submitted medical records show that Zypitamag was prescribed to treat the enrollees pure hypercholesterolemia. The Medicare approved compendia support the use of the requested drug for this condition. However, the submitted documentation does not sufficiently address why all of the alternative drugs listed in the plans formulary to treat pure hypercholesterolemia have not been tried, or are contraindicated. Therefore, the plan will not cover the Zypitamag as an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azasan 75 milligrams prescribed daily for enteropathic arthropathies. The Part D plan denied your request because the enrollees plan coverage termed on January 31, 2021. We received an expedited request from the appellant to reconsider the appeal.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 the enrollees plan coverage termed on January 31, 2021. We determined that the plan is not required to cover the Azasan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Estradiol Micronized Powder 1.6-milligram per milliliter compounded capsules from bulk powder.  The Part D plan denied your request because Bulk powders are not FDA approved and are therefore not covered under Part D.   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 Estradiol Micronized capsules compounded capsules from bulk powder.Drugs compounded from Bulk powders are not FDA approved and are therefore not covered under Part D.   The plan is therefore not required to cover the Estradiol Micronized Powder at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Livalo (Pitavastatin) 4 milligram tablets for hyperlipidemia. 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.This drug is being provided by the plan under a formulary exception. It 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Codeine-Butalbital-Acetylsalicylic Acid-Caffeine capsules prescribed for the diagnosis of chronic migraine without aura, not intractable. 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. 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. Medicare approved compendia does not support the use of this medication for the diagnosis submitted. Therefore, it is ineligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover Codeine-Butalbital-Acetylsalicylic Acid-Caffeine capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Adefovir Dipivoxil 10 milligram tablets for hepatitis B. The Part D plan denied your request for a tiering exception because the drug is considered a specialty drug which is excluded from being provided at a lower cost-share. 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. Adefovir Dipivoxil is listed as a specialty drug on Tier 5 of the plans formulary and is not eligible for a Tier exceptions. 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 Enbrel 50 mg/ml syringe to treat your condition. The request was for a 90 day supply. The Part D plan denied the request stating that this biologic is a specialty biologic and is limited to a 30 day supply per plan policy. 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 biologic you requested is a specialty biologic. Your Prescription Drug Guide says that specialty biologics are limited to a 30-day supply. The 30-day supply limit on specialty biologics also applies to mail-order. The plan is not required to cover a greater than 30 day supply.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisolone Acetate 1% ophthalmic solution prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the prescriber did not address all alternatives were tried and failed. 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.Prednisolone Acetate is a generic drug on Tier 3 of the plans formulary. Your doctor submitted a supporting statement. The statement did not address why all alternative lower-tier medication on the plans formulary would not work for you. All generic drugs on lower tiers have not been tried. 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 Diovan 320 milligrams tablet to treat hypertension. 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 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 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

At issue is Humira 40milligrams per 0.8 milliliter syringe to treat ankylosing spondylitis. 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 Disopyramide Phosphate 150 milligrams prescribed three times daily for unspecified atrial fibrillation. 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. 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 drugs 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 Disopyramide Phosphate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica 150 milligram capsules prescribed twice daily for dorsalgia. 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. 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 drugs 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 Lyrica.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexium DR, 40 milligram capsules prescribed for gastroesophageal reflux disease. 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 requested and submitted at the reconsideration level. A physician reviewed your appeal and determined that the plan is not required to cover the Nexium DR. The submitted documentation shows that the drug was prescribed to treat gastroesophageal reflux disease. The Medicare approved compendia support the use of the requested drug for this condition. However, the submitted documentation does not include the enrollees medical records to validate that the plan's prior authorization coverage criteria for the Nexium DR have been satisfied.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligram per 2 milliliter pen to treat atopic dermatitis and pruritus. 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 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.A physician reviewed your appeal and determined that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Flovent Diskus 250 microgram blister with inhalation device prescribed to treat eosinophilic esophagitis. 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 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 Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of your condition. Therefore, this drug is not eligible for a tiering exception.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 a tiering exception request for Dilantin 100mg capsule to treat a seizure disorder.   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.Dilantin 100mg capsule 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 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 Leflunomide 20 milligram tablets prescribed daily for rheumatoid arthritis. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information about your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why similar medications on the lower teirs would not work for you.  We received the documentation and included it in our review.Leflunomide is a generic drug on Tier 3 of the plans formulary. Your doctor submitted a supporting statement. The statement said Leflunomide was prescribed to treat rheumatoid arthritis. Alternative drugs from the lower cost level tiers such as Hydroxychloroquine, Arava, and Methotrexate have been tried. These drugs caused adverse effects such as gastrointestinal issues and blood pressure issues. However, the plans formulary also includes Azathioprine, a generic drug which is the same class as Leflunomide, on Tier 2. Your doctor did not address why Azathioprine would not work for you. All generic drugs on lower tiers have not been tried. 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.