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

At issue is Onglyza 5 milligram tablets prescribed for type 2 diabetes mellitus. The Part D plan denied your 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. Onglyza is a brand drug on Tier 4 of the plans formulary. Your doctor did not address why all drugs available on the lower tiers of your plans formulary would not work for you. 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: Favorable

At issue is Otezla 30 milligram tablet prescribed twice daily for plaque psoriasis. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any records submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We received the documentation and included it in our review.The medical records show the doctor prescribed Otezla to treat the enrollees plaque psoriasis. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The prescriber states the enrollees psoriasis involves greater than 5% body surface area. The medical records show that the enrollee has tried and failed one topical treatment and Methotrexate. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Simvastatin Suspension 20 milligram/5 milliliters prescribed for hyperlipidemia. The Part D plan denied your request stating the drug has a marketing end date on the Comprehensive NDC SPL Data Elements File.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. Simvastatin Suspension does not have an end marketing date on the Comprehensive NDC SPL Data Elements File. However, the drug is not on the plans formulary. There is no documentation submitted as to why the enrollee cannot use an alternative drug on the plans formulary such as FloLipid (Oral Suspension).In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Simvastatin Suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Asenapine 2.5 milligram sublingual tablet for treatment of restlessness and agitation and unspecified intracranial injury with loss of consciousness. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.The prescriber statement shows Asenapine was prescribed for treatment of  mood disorder due to traumatic brain injury. 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 Asenapine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Levalbuterol 0.63 milligram per 3 milliliter solution prescribed for chronic obstructive pulmonary disease. 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. Your medical records show Levalbuterol was prescribed to treat chronic obstructive pulmonary disease and is being used via nebulizer in the home. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Therefore, coverage under Part D is excluded for any drug for which payment would be available under Part B. We determined that the plan is not required to cover Levalbuterol. This drug may be eligible for coverage under Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zelnorm 6 milligram tablet, 60 per 30 days prescribed for irritable bowel syndrome with 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. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the list, the manufacturer, Alfasigma USA, Inc. did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Zelnorm. 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 Ezetimibe 10 milligram oral tablet. The Part D plan denied your 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. Ezetimibe is a generic drug on Tier 3 of the plans formulary. There are no 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rexulti 2 milligram tablets prescribed once a day for major depressive disorder, recurrent. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We requested additional documentation from your prescriber but did not receive a response. There are no medical records to support a diagnosis and to determine if the drug requested is medically indicated for your condition your condition. A physician reviewed your appeal and determined that the plan is not required to cover Rexulti.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% patch prescribed for chronic neck and back pain. 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 records submitted at the reconsideration level. Your medical records show your doctor prescribed Diclofenac Epolamine to treat your chronic neck and back pain. Your plan has prior authorization requirements for this drug that must be met 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 chronic neck and back pain. The requested drug is not approved to be used for chronic pain. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 0.5 milligram tablets prescribed twice daily for common variable immunodeficiency. 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 documentation shows your doctor prescribed Tacrolimus common variable immunodeficiency. 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 Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Uribel 118 milligram capsules prescribed for bladder spasms. The Part D plan denied your request stating the drug has a marketing end date on the Comprehensive National Drug Code, Structured Product Labeling, Data Elements File.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. Uribel capsules has an end marketing date on the Comprehensive National Drug Code, Structured Product Labeling, Data Elements File of January 31, 2020. There are no food and drug administration approved uses for this drug. Non-FDA approved drugs are excluded from Medicare Part D coverage.   Therefore, it is excluded from Part D drug benefit coverage. A physician reviewed your appeal and determined that the plan is not required to cover Uribel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate 500 milligram oral tablet prescribed daily for uveitis. 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 documentation shows your doctor prescribed Mycophenolate to treat your uveitis and birdshot retinochoroiditis . 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 Mycophenolate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for neuropathic pain secondary to back injury which damaged the lateral cutaneous nerve. 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 documentation shows your doctor prescribed Lidocaine 5% patch to treat your neuropathic pain secondary to back injury which damaged the lateral cutaneous nerve. 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 Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil 100 milligram oral tablet prescribed for erectile dysfunction. 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. We determined that the plan is not required to cover Sildenafil because it was used to treat sexual or erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction 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 Pregabalin 50 milligram capsules prescribed for chronic back pain. 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 documentation shows your doctor prescribed Pregabalin to treat your chronic back pain. 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 Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levemir 100 units/milliliter vial prescribed for type 2 diabetes mellitus with hyperglycemia. The Part D plan denied your 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. Levemir 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Silodosin 4 milligram capsules prescribed for benign prostatic hyperplasia with lower urinary tract symptoms. 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. We requested medical records from your prescriber to support other medications tried and we did not receive a response. In this case, the medical records do not support why other drugs on the plans formulary, for your condition, would not work for you. There is no supporting evidence that the plans formulary alternative drugs have been tried.A physician reviewed your appeal and determined that the plan is not required to cover Silodosin capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ergocalciferol 1.25-milligram capsule to treat osteoporosis. 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.Drugs prescribed for use as vitamins and minerals are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.A physician reviewed the appeal and determined that the requested drug is excluded from Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Pen Needles 32 gauge/4-millimeters to treat the enrollees condition. 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.Pen Needles are on Tier 3 of the plans formulary. There are no other Pen Needles of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, the Pen Needles are 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 Oxycontin Extended Release 60 milligram tablets prescribed for chronic pain. 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why all other drugs on the plans formulary would not work for you. There is no supporting evidence that all the plans formulary, alternative drugs, have been tried.A physician reviewed your appeal and determined that the plan is not required to cover Oxycontin Extended Release tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligram extended release tablet prescribed daily for over-active bladder and urinary urgency. The Part D plan denied your 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. Myrbetriq 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Rexulti 1 milligram tablet to treat the enrollees condition.   The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.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 Cyclobenzaprine Hydrochloride 10 milligram oral tablets prescribed daily for cervicalgia. 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 documentation shows your doctor prescribed Cyclobenzaprine Hydrochloride to treat your cervicalgia. 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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluorometholone 0.1% eye drops for post corneal transplant, both eyes. The Part D plan denied your 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. Your provider stated Fluorometholone is a generic drug on Tier 3 of the plans formulary. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you. 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 Butalbital-Aspirin-Caffeine 50-325-40 milligram tablet prescribed for migraine headaches, fibromyalgia, rheumatoid arthritis, and osteopenia.  The Part D plan denied the request stating that the provided diagnoses are non-medically accepted indications.  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.  In the Reconsideration appeal medical records were requested and were not provided.The use of the requested drug to treat the provided diagnoses 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 conditions.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate Hydrochloride 5 milligram tablets prescribed for anoxic brain damage not elsewhere classified. 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 documentation shows your doctor prescribed Methylphenidate Hydrochloride to treat your anoxic brain damage not elsewhere classified. 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 Methylphenidate Hydrochloride.