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

At issue is Recombivax 5 micrograms/5 milliliter suspension. The Part D plan denied the request stating there was missing information to determine whether coverage is provided under your Part D plan. 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.We requested a prescribers statement and medical records from your doctor. Your doctor wrote that he did not order the medication. Without a diagnosis and medical records, it cannot be established if your Part D plan is required to provide coverage. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cefdinir 300 milligram capsules prescribed twice daily for extradural and subdural abscess, unspecified. The Part D plan denied your request for a formulary exception because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Cefdinir 300 milligram capsules to treat your extradural and subdural abscess. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and determined  that the plan is not required to cover Cefdinir because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxycontin ER 15 milligram tablet prescribed to treat the enrollees condition. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We asked the prescriber to send us a detailed receipt. However, we did not receive the documentation.. A physician reviewed your appeal and determined that the plan is not required to reimburse you for the Oxycontin ER 15 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate Hydrochloride 10 milligram tablets. The Part D plan denied coverage because the medication was being prescribed for a non-medically accepted indication. 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 records submitted at the reconsideration level. The medical records submitted at redetermination indicate that Methylphenidate Hydrochloride is being prescribed to treat the enrollees restlessness and agitation secondary to the presence of autism, intellectual disability, and cerebral palsy. However, the medical records submitted at reconsideration indicate that Methylphenidate Hydrochloride is being prescribed to treat the enrollees attention deficit hyperactivity disorder.During this review, a statement from the prescribing physician was requested to validate and clarify what diagnosis the Methylphenidate Hydrochloride was being prescribed for, as the medical records contain conflicting information. However, a prescriber statement was not received by the physician.Therefore, it is not possible to determine if the medication is being prescribed for a medically accepted indication. 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 Victoza 18 milligrams/3 milliliters subcutaneous to treat Type 2 diabetes mellitus with hyperglycemia. The Part D plan auto-forwarded the appeal to us for reconsideration.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has not indicated that all alternatives required by the plan have been tried and failed, or why the plans required step therapy drugs would likely not be as effective as the requested drug.  Our physician reviewer's opinion is that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate HCL 20 milligram tablets prescribed four times daily for idiopathic hypersomnolence. 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 Methylphenidate HCL 20 milligram tablets to treat your idiopathic hypersomnolence. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.  A physician reviewed your appeal and determined  that the plan is not required to cover Methylphenidate HCL because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 micrograms blisters with device prescribed daily for chronic obstructive pulmonary disease. 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. Anoro Ellipta 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

At issue is Xarelto 20 milligram tablets prescribed daily for anticoagulation secondary to paroxysmal atrial fibrillation. 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. Xarelto 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

At issue is Ilumya 100 milligrams/milliliter injection to treat plaque 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. We also researched Medicare systems and reviewed the enrollment data available. 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Ilumya. A physician reviewed your appeal and determined that the plan is not required to cover Ilumya because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cromolyn Sodium 20 milligram/2 milliliter nebulizer solution prescribed as directed for mild intermittent asthma, uncomplicated. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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 Cromolyn Sodium 20 milligram/2 milliliter nebulizer solution to treat your mild intermittent asthma, uncomplicated. However, we determined that the drug is not eligible for Part D coverage. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. 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 Cromolyn Sodium 20 milligram/2 milliliter nebulizer solution because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit.You may wish to submit a request for Cromolyn Sodium 20 milligram/2 milliliter nebulizer solution to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Octreotide acetate 100 micrograms/milliliter syringe for subcutaneous injection prescribed 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.Octreotide acetate 100 micrograms/milliliter syringe for subcutaneous injection is a generic drug on Tier 4 of the plans formulary. The prescriber has not provided patient specific clinical rationale, with supporting medical documentation, to indicate that all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  Therefore, this drug is not eligible for a tiering exception. It is noted that Octreotide acetate 50 micrograms/milliliter vial is available on Tier 3 of the plans formulary.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% ointment. The Part D plan denied coverage because the medication was being prescribed for a non-medically accepted indication. 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. The documentation indicates that Lidocaine 5% ointment is being prescribed due to pain from third-degree hemorrhoids.During this review, a statement of medical necessity and medical records were requested from the prescribing physician to validate the diagnosis for the Lidocaine 5% ointment prescription.  However, the physician did not submit a prescriber statement or any medical records. Therefore, it is not possible to determine if the medication is being prescribed for a medically accepted indication. 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 Amantadine HCL 100 milligram tablet to treat fatigue related to multiple sclerosis.   The Part D plan denied the request.  The requested drug is not on the plans formulary. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to 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 formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.  Please note that Amantadine capsules and solution are available on the formulary.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo solution 600 micrograms/2.4 milliliter injection pen prescribed as directed for osteoporosis. 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 you were prescribed Forteo injection pen for your condition. 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 coverage criteria has been met. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Forteo injection pen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol sulfate 2.5 milligrams per 3 milliliter vial prescribed as directed via nebulizer for chronic bronchitis and asthma. 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 record shows the doctor prescribed Albuterol sulfate for chronic bronchitis and asthma. However, this drug is eligible for coverage under Medicare Part B. Medicare Part B covers this drug for obstructive pulmonary disease, when used with a nebulizer in the home (or in an assisted living facility). Medicare Part D cannot pay for drugs that are covered by Medicare Part B.We reviewed your appeal and determined that the plan is not required to cover Albuterol sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Glucovance (Glyburide 2.5 milligrams and Metformin 500 milligrams) to treat the diagnosis of diabetes. The Part D plan denied the request because the documentation was insufficient to meet the non-formulary exception rules. We received an expedited reconsideration 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.Glucovance is not on the plans formulary. A request was submitted for the prescribers statement and to provide supporting medical records. However, a reply from the prescriber was not received. The documentation is insufficient to support the medical necessity for the requested drug. Therefore, an exception to the plans formulary coverage criteria is not supported.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 100 milligram tablets prescribed as directed for fatigue related to multiple sclerosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The record shows the physician prescribed Modafinil for fatigue related to multiple sclerosis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Belbuca 450 microgram buccal film prescribed for chronic back pain. The Part D Plan denied your request for a tiering exception because the records did not explain why alternative brand name drugs in lower cost-share tiers wouldnt work just as well. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Belbuca 450 microgram buccal film 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 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 Carbamazepine 400 milligram tablets to treat generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus. 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. Carbamazepine is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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 Ipratropium/Albuterol 0.5-2.5 milligrams/3 milliliter nebulizer solution prescribed as directed for shortness of breath. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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 Ipratropium/Albuterol nebulizer solution to treat your shortness of breath. However, we determined that the drug is not eligible for Part D coverage. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. 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 Ipratropium/Albuterol nebulizer solution because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit.You may wish to submit a request for Ipratropium/Albuterol nebulizer solution to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Solu-cortef 100 milligram injection prescribed as directed to treat adrenocortical insufficiency. 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 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 that your doctor prescribed Solu-cortef to treat your condition. 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 Solu-cortef because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Dexilant 60 milligram capsules to gastroesophageal reflux 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.Dexilant 60 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 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

You requested Methylphenidate HCL 5 milligram tablets prescribed daily for multiple sclerosis. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request.  We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Methylphenidate HCL 5 milligram tablets to treat your multiple sclerosis. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.  A physician reviewed your appeal and determined  that the plan is not required to cover Methylphenidate HCL because it was not prescribed for a medically accepted indication.