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

At issue is a tiering exception request for Trelegy Ellipta to treat chronic obstructive lung disease. The Part D plan denied your request for a tiering exception because the drug is already being provided to you at the lowest cost-share amount allowed by the plan as there are no lower Tier brand alternatives available on the formulary to treat the same 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 plans formulary.Trelegy Ellipta is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary 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 Cyclobenzaprine Hydrochloride 10 milligrams to treat diagnoses pain in unspecified joint; radiculopathy, cervical region; spinal stenosis; cervical region; pain in thoracic spine; and other spondylosis with myelopathy, cervical region that were noted on your reconsideration request. 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 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 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 your condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Daurismo 100 milligram tablets prescribed daily for acute myeloid leukemia with multilineage dysplasia on February 12, 2021. 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 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Daurismo to treat your  acute myeloid leukemia with multilineage dysplasia, not having achieved remission. The prescriber submitted records including that the acute myeloid leukemia was initially diagnosed in 2014.  The Medicare approved compendia do support the use of this drug for your condition only when the drug is used in combination with low-dose Cytarabine. The documentation provided does not show that Daurismo was used in combination with Cytarabine and therefore does not satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Daurismo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zyflo 600 milligrams immediate release tablets prescribed four times daily for mast cell activation syndrome and mild persistent asthma. The Part D plan denied your request for a tiering. 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. Zyflo is a brand drug that is not on the plans formulary. Medicare has already granted a formulary exception for the drug. A tiering exception cannot be allowed for a drug that is not on the plans formulary. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Zyflo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rhopressa 0.02% eye drops prescribed for glaucoma. 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 documentation indicates the physician had prescribed Rhopressa to treat your glaucoma. The Medicare approved compendia support the use of the requested drug for your condition.However, 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 Rhopressa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets (42/14) prescribed for small intestinal bacterial overgrowth. 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 information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed the drug for small intestinal bacterial overgrowth. The Medicare approved compendia do not support the use of this drug for your condition. 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Simbrinza eye drops prescribed to reduce intraocular pressure for open-angle glaucoma. The Part D plan denied your request for a tiering exception because Simbrinza is a Tier 3 medication with no alternate brand drugs on a lower tiers. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The records show Simbrinza 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 cover the drug at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 50 milligrams tablet prescribed for urinary incontinence. The Part D plan denied your request for a tiering exception. We received a reconsideration request from the plan. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows 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 for the enrollees condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Myrbetriq.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 72 micrograms prescribed as directed for irritable bowel syndrome with constipation. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an auto-forwarded 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 that your doctor prescribed Linzess to treat your condition. The Medicare approved compendium supports the use of this drug to treat your condition. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Linzess because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Forteo 6.20 micrograms/2.48 milliliter pen prescribed for the enrollees age-related osteoporosis. 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 submitted at the reconsideration level. The enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee was prescribed Forteo due to being a high risk of osteoporotic fractures due to a significant loss of bone mineral density.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vivelle Dot 0.05 milligram patch prescribed for menopausal hormone therapy. The Part D plan denied the request because the enrollee purchased a quantity greater than what was prescribed at an out-of-network pharmacy. 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.The record shows you purchased the drug at issue at an out-of-network pharmacy. Your doctor prescribed one patch every three to four days for 30 days. You purchased a quantity of supplies for 84 days. The plan has reimbursed you for the quantity of supplies purchased for the covered 30 days.We determined that the plan is not required to reimburse you for the Vivelle Dot patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolic Acid 360 milligrams prescribed for birdshot chorioretinopathy. The Part D plan denied your request because the medication is 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 records show you prescribed Mycophenolic Acid to treat the enrollees birdshot chorioretinopathy. 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 Mycophenolic Acid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Northera 100 milligram tablets to treat chronic hypotension. The Part D plan denied the request for not meeting prior authorization requirements. 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 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 your condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 Clonidine 0.3 milligram/day patch prescribed to treat hypertension. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Clonidine 0.3 milligram/day patch is a generic drug on Tier 4 of the plans formulary. There are no generic 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 cover Clonidine 0.3 milligram/day patch because there are no generic drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium-Albuterol 0.5/2.5 milligrams ordered by nebulizer four times daily for chronic obstructive pulmonary disease. 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 record shows the Ipratropium-Albuterol solution was ordered for the enrollees condition. However, this drug is eligible for coverage under Part B.We determined that the plan is not required to cover the Ipratropium-Albuterol nebulizer solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Autologous Serum Tears, 50% ophthalmic solution one drop in each eye four times daily, for the treatment of dry eye syndrome. Autologous Serum Tears is a compound eye drop that contains balanced salt solution and the enrollees own blood. The Part D plan denied the serum component of the medication because Part D plans do not cover any blood products. The Part D plan denied the balanced salt solution component of the medication because dry eye syndrome is not a medically accepted indication for the use of balanced salt solution. 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 balanced salt solution because dry eye syndrome is not a medically accepted indication to use this drug. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore the requested drug is not being prescribed for a medically accepted indications as defined by Medicare law.  As such, the requested drug does not meet the definition of a Medicare Part D drug and is therefore not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone 1% gel prescribed for testosterone deficiency. The Part D plan denied your request because the medication is 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 records show you prescribed Testosterone gel to treat the enrollees testosterone deficiency. 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 Testosterone gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Januvia 100 milligram tablets prescribed once daily for type II diabetes mellitus. You requested that the plan provide a tiering exception for this drug. The plan did not make a decision within the required timeframe. 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. Januvia 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

You requested Diclofenac 3% gel prescribed for neck and back pain. The Part D plan denied your request because the medication is 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 records show you prescribed Diclofenac gel to treat the enrollees pain. 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 Diclofenac gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prosol 20%-Clinolipid 20%-Dextrose 70% compounded intravenous solution prescribed as directed for malnutrition. You requested that the plan provide coverage for a prior authorization drug, Prosol, and two non-formulary drugs, Clinolipid and Dextrose. The plan did not make a decision within the required timeframe. 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. The documentation shows the physician had prescribed Prosol-Clinolipid-Dextrose intradialytic parenteral nutrition to treat malnutrition. The physician states that the enrollee has a functioning gastrointestinal tract. The case file includes a prior authorization approval letter for Prosol, showing that Prosol has been approved from January 11, 2021, through February 10, 2022. The Medicare approved compendium does support the use of Clinolipid and Dextrose for the enrollees condition. However, the records do not show that the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Prosol-Clinolipid-Dextrose.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pradaxa 150 milligrams prescribed daily for anticoagulation with atrial fibrillation. 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 submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show you were prescribed Pradaxa for atrial fibrillation. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided do not show the plan's coverage criteria has been met.A physician reviewed your appeal and determined that the plan is not required to cover the Pradaxa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Desvenlafaxine Succinate Extended Release 100 milligram tablets to treat depression. 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.Desvenlafaxine Succinate is a generic drug on Tier 4 of the plans formulary. The plans formulary includes other generic medications on lower Tiers that are the same class and for the same condition. The prescriber did not address why all the other medications were not tried or why they feel they might result in an adverse effect. 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 Wixela inhub prescribed for chronic bronchitis and chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception. We received a reconsideration request from the plan. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows Wixela is a generic drug on Tier 3 of the plans formulary. There are no alternative drugs of the same type on the lower cost sharing tiers for the enrollees condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Wixela.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Minoxidil compound powder. The Part D plan denied the request stating that the medication cannot be paid by Part D when in a compounded form. 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 use of the requested drug is not Food and Drug Administration approved in the form requested.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.