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

You requested Erythromycin 400 milligram/5 milliliter solution was prescribed to treat vomiting, unspecified severe protein-calorie malnutrition, gastroparesis, other disease of stomach and duodenum and failure to thrive (child). The Part D plan denied your request because the diagnoses submitted were not medically accepted indications for the requested drug and the requested drug was not listed on the plans formulary. 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 prescriber statement shows Erythromycin was prescribed to treat the enrollees conditions. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: 'Erythromycin demonstrated increased gastric emptying for gastroparesis syndrome.'However, 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 prescribers statement does not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Erythromycin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nifedipine 90 milligram extended release tablets prescribed for the enrollees condition. 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 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.We requested additional information from the prescriber. Specifically, we requested a prescriber statement to support all lower-tier medication were tried and failed. However, we did not receive the requested documentation.Nifedipine is a generic drug on Tier 2 of the plans formulary. The submitted documentation did not address why all the drugs available on the lower tiers of the plans formulary would not work. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tobramycin 80 milligrams per 2 milliliters vial for injection prescribed to treat pneumonia and sepsis of unknown organism.The QIC 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 shows the doctor prescribed Tobramycin 80 milligrams per 2 milliliters vial for injection to treat pneumonia and sepsis of unknown organism. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Tobramycin 80 milligrams per 2 milliliters vial for injection.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Memantine Hydrochloride 21 milligram extended release capsule prescribed to treat cognitive impairment. We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file and all documentation submitted. This includes any information submitted at the reconsideration level. The prescriber indicates Memantine Hydrochloride 21 milligram extended release capsule is prescribed to treat cognitive impairment. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Memantine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsule prescribed for circadian rhythm sleep disorder, free running type. 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. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Additional information was requested from the prescriber but we did not receive the necessary information. The enrollee has not satisfied the plan's coverage criteria.  A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz. 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

At issue is Gammagard 5-grams/50-milliliters to treat nonfamilial hypogammaglobinemia. 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.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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Enlyte Softgel. 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 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 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.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 coverage for Dupixent 300 milligram per 2 milliliter prefilled subcutaneous injection syringe prescribed for moderate to severe atopic dermatitis. 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 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 has prior authorization requirements that must be met before coverage of this medication will be approved. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Shingles vaccine prescribed for vaccination.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the enrollee paid full price for the Shingles vaccine and administration fee. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, documentation was provided showing the plan provided reimbursement based on the enrolllees cost share benefit stage. The plan will only reimburse up to the contracted price of the drug, minus any deductible, copay or coinsurance. We determined that additional reimbursement is not required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Botox 200 units powder for solution prescribed for vulvodynia, other muscle spasms, bladder disorder, and pelvic/perineal pain. 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 submitted documentation indicates the prescriber ordered Botox for vulvodynia, other muscle spasms, bladder disorder, and pelvic/perineal pain. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested Botox.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 200-milligram tablet to treat abdominal distention (gaseous)/bloating, gastroesophageal reflux disease, and small intestinal bacterial overgrowth. 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.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Levofloxacin 750 microgram tablet.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee received Levofloxacin as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a hospital statement showing the drugs that were self-administered and the charged amount. However, proof of payment in the form of a receipt was not provided. Therefore, we determined that the plan is not required to reimburse the enrollee for the Levofloxacin without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Vardenafil Hydrochloride (Levitra) 10 milligram tablets. 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. The documentation indicates that Vardenafil Hydrochloride has been prescribed for the treatment of erectile dysfunction. However, drugs when used for the treatment of sexual or erectile dysfunction are excluded from coverage under Medicare Part D. Therefore, the Vardenafil Hydrochloride is not eligible for coverage under Medicare Part D. 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

At issue is Hetlioz 20 milligram capsule prescribed for circadian rhythm sleep disorder, free running type. 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. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation does not indicate all of the plans coverage criteria have been satisfied.  A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz. 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

At issue is Myrbetriq ER 25 milligram tablet prescribed daily for frequency of micturition. 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 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. Myrbetriq ER 25 milligram tablet  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. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500-milligram tablet to treat sarcoidosis. 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.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 Stelara 45 milligram/0.5 milliliter solution prefilled syringe prescribed as directed for rheumatoid arthritis of multiple sites with negative rheumatoid factor. 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Stelara to treat your rheumatoid arthritis of multiple sites with negative rheumatoid factor. 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, as ordered, is not being used for a medically accepted indication. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules. The requested drug is not eligible for coverage under Medicare Part D.a.A physician reviewed your appeal and determined that the plan is not required to cover Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Dilantin 100 milligram capsules prescribed for epilepsy. 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. Dilantin in the strength of 100 milligrams is not on the plans formulary, but the plan has agreed to provide it at a Tier 4 cost-sharing level. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Promethazine Hydrochloride 6.25 milligram/5 milliliter syrup prescribed for chronic sinusitis with cough. 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 Promethazine Hydrochloride to treat your chronic sinusitis with cough. 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 Promethazine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Erythromycin Ethylsuccinate (E.E.S.) 200 microgram per 5 milliliters suspension prescribed to treat paralytic megacolon and severe gastroparesia. The Part D plan denied the appeal request.The QIC 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 shows the doctor prescribed E.E.S. 200 microgram per 5 milliliters suspension to treat paralytic megacolon and severe gastroparesia. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover E.E.S. 200 microgram per 5 milliliters suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Androderm Patch 2 milligram/24 hour prescribed as directed. 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. Androderm Patch 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 Entresto 97/103 milligram tablets prescribed as directed. 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. Entresto 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 Diclofenac Sodium 1% gel prescribed two grams four times daily for shoulder pain due to a rotator cuff tear, bursititis, and tendinopathy. 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 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 doctor prescribed Diclofenac Sodium 1% gel to treat the enrollees shoulder pain due to a rotator cuff tear, bursititis, and tendinopathy. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed the appeal and determined that the plan is not required to cover Diclofenac Sodium 1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xiidra 5% eye drops prescribed twice daily for dry eye syndrome. 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 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 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. A physician reviewed the appeal and determined that the plan is not required to cover Xiidra 5% eye drops.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablet prescribed for postural orthostatic tachycardia syndrome. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. The prescriber indicates that Corlanor 5 milligram tablet is prescribed for postural orthostatic tachycardia syndrome. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Cresemba 186 milligram capsule prescribed to treat candidiasis, unspecified. 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. This drug is included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.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 Rytary ER 48.75-195 milligram capsule prescribed one to two capsules three times daily for Parkinsons disease. 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 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. Rytary ER 48.75-195 milligram capsule 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. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.