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

You requested Clobazam 10 milligram tablets prescribed daily for partial epilepsy and epileptic syndromes with complex partial seizures, intractable. The Part D plan denied your request because the provided diagnosis 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Clobazam 10 milligram tablets to treat your intractable, symptomatic epilepsy with complex partial seizures without status epilepticus. Seizures have been ongoing for years, with use of Clobazam since 2014. You have also been treated with Vimpat, Depakote, and Tegretol. The Medicare approved compendia do support the use of this drug as a medically accepted indication for your condition. In Micromedex, a Medicare approved compendia, a positive citation was identified. It states  Clobazam in doses of 20 mg daily initially (increasing to 30 or 40 mg daily if required) was reported effective as add-on therapy in drug-resistant epilepsy in an uncontrolled study involving 30 patients. All patients had epilepsy of at least 10 years' duration, with an average of 7 seizures monthly during the 3 months prior to initiation of clobazam therapy; 18 patients had focal epilepsy (primarily temporal lobe type with partial complex seizures) and 12 patients had primary generalized seizures. At an average of 28 months of follow-up, seizure frequency was reduced by greater than 70% in 13 patients (43%) and by 50 to 75% in 7 patients (24%). Side effects were minimal during therapy. Medication is being prescribed by a neurologist.The documentation does not satisfy the plans coverage criteria.  However, the prescriber has indicated why all alternatives required by the plan would likely not be as effective as the requested drug for you, or would likely cause adverse reaction(s). Therefore, an exception to the plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuedexta 20-10 milligram capsule prescribed twice daily for pseudobulbar affect. The Part D plan denied your request for a tiering 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.Nuedexta 20-10 milligram capsule is a brand drug on Tier 5 of the plans formulary, also know as the specialty tier. Part D drugs placed on the specialty tier 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 Repatha Sureclick 140 milligram per milliliter auto-injector 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.Repatha is not on the plans formulary. The prescriber has not supplied a supporting statement, along with supporting medical records, to explain why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 50 milligrams tablets. The Part D plan denied your request for a tiering exception. 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 documentation shows Myrbetriq ER 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 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 grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexium 40 milligram tablets prescribed for Barretts esophagus. 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. The documentation does 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 Nexium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Janumet 50/1000 milligram tablet prescribed twice a day for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. 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.Janumet 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 Eliquis 5 milligram tablets for treatment of the enrollees condition. The Part D plan denied your request for a tiering 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.Eliquis 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.A physician reviewed the appeal and determined that the that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Corlanor 7.5 milligram tablets prescribed twice daily for postural orthostatic tachycardia syndrome. The Part D plan denied your request because the provided diagnosis 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Corlanor 7.5 milligram tablets to treat your postural orthostatic tachycardia syndrome. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and determined that the plan is not required to cover Corlanor because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent patch prescribed for chronic back pain, fibromyalgia, and nerve pain. The Part D plan denied your request because the provided diagnoses do 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. We also researched Medicare systems and reviewed the enrollment data available. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5 percent patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta 50 milligram oral tablet to treat nerve pain due to trigeminal neuralgia.   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 sent a statement clarifying the medical history.  Relevant medical records were requested but not provided. 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 Cialis 5 milligrams prescribed for scleroderma and Raynauds syndrome. 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. The physician submitted a supporting statement. The documentation indicates the physician had prescribed Cialis to treat Raynauds syndrome. The Medicare approved compendia support the use of the requested drug for your condition.However, the physician did not indicate all alternatives to treat the enrollees 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 Cialis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram to treat sinus tachycardia and premature ventricular contractions.  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

At issue is Hetlioz 20 milligrams prescribed daily for non-24 hour sleep-wake disorder. The Part D plan denied coverage because 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. Your medical records show your doctor prescribed Hetlioz 20 milligrams daily for non-24 hour sleep-wake disorder. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records 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 the Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Estrace 0.1 milligram cream prescribed for atrophy and vaginal pain. The plan denied the request. We received a standard 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 rules and the plans formulary.Estrace is a generic drug on Tier 3 of the plans formulary. There are no drugs of the same type on lower tiers of 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 grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Modafinil 200 milligrams 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.Modafinil 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 Farxiga 10 milligram tablets. 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. Farxiga 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. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Naltrexone Hydrochloride 3 milligram tablets prescribed for opioid dependence from fibromyalgia. The Part D plan denied your request because bulk powders are not Food and Drug Administration approved and are therefore not covered under Medicare Part D. 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 Naltrexone Hydrochloride was compounded from bulk powder. Drugs compounded from Bulk powders are not approved by the Food and Drug Administration. Therefore, the plan is not required to cover Naltrexone Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram oral tablet prescribed twice daily for paroxysmal atrial fibrillation. The Part D plan denied your request for a tiering 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. Eliquis 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 Lidocaine Patch 5% to treat pain, unspecified. The Part D plan denied your request. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The documentation submitted does not support the use of the drug for the condition reported. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine Patch 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nitro-Bid 2 % Ointment to treat Raynauds syndrome without gangrene. The Part D plan denied your request. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees condition. The drug is not approved by the food and drug administration to treat the diagnoses submitted. 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 Nitro-Bid Ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligram tablets prescribed twice a day for psoriasis. 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. Specifically, the guideline requires you to try Cosentyx and Skyrizi.A physician reviewed your appeal and determined that the plan is not required to cover Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

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.We determined that the drug is not eligible for Part B coverage. Therefore, the drug can be considered for payment under the Part D benefit.Dronabinol 10 milligram capsule was ordered to treat the enrollees chronic nausea and anorexia. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Eliquis 5 milligram tablets. The Part D plan denied your request for a tiering exception because there were no other similar drugs on a lower cost-sharing tier. 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.Eliquis is a brand drug on Tier 3 of your plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. Therefore, a tiering exception cannot be granted for the Eliquis.A physician reviewed your appeal and determined that the plan is not required to cover the Eliquis at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 25 milligram tablets prescribed as directed for overactive bladder. The Part D plan denied your request for a tiering exception because there were no brand drugs of the same type on the lower cost sharing 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. 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 Suboxone 8 milligram-2 milligram sublingual film prescribed for opioid dependence. The Part D plan denied your request because the documentation did not support an off-formulary 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. The documentation indicates the physician had prescribed Suboxone to treat opioid dependence. 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 Suboxone.