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

You requested Amphetamine-Dextroamphetamine Extended Release, 20-milligram capsule prescribed one capsule, twice daily for daytime sleepiness, poor energy/motivation, anhedonia associated with severe major depressive disorder, recurrent severe without psychotic features. The Part D plan denied your request because your diagnoses did not meet the requirements of a medically accepted indication. As such, the request for a quantity limit exception could not be granted. 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 Amphetamine-Dextroamphetamine Extended Release (Adderall Extended Release) to treat your daytime sleepiness, poor energy/motivation, anhedonia associated with severe major depressive disorder, recurrent severe without psychotic features. However, the Medicare approved compendia do not support the use of this drug for your conditions. A physician reviewed your appeal and determined that the plan is not required to cover Amphetamine-Dextroamphetamine Extended Release because you do not have a medically accepted indication for its use.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 200 milligrams prescribed daily for chronic respiratory failure with hypercapnia and acute respiratory failure with hypoxia. The Part D plan denied your request 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.The submitted documentation shows your doctor prescribed Modafinil to treat your chronic respiratory failure with hypercapnia and acute respiratory failure with hypoxia. 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 Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydroxychloroquine sulfate 200 milligrams prescribed twice daily for frontal fibrosing alopecia. The Part D plan denied your request because it 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 Hydroxychloroquine sulfate 200 milligrams twice daily to treat your frontal fibrosing alopecia. 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 Hydroxychloroquine sulfate 200 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 2 milligram tablets prescribed for pure hypercholesterolemia. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Livalo as an off-formulary exception.Your doctor submitted a supporting statement and medical records. The medical records show that Livalo was prescribed to treat your pure hypercholesterolemia. 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. While your doctor stated you did try two other medications for your condition, there are other drugs listed on your plans formulary to treat your condition that have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac 0.1% topical prescribed four times daily for osteoarthritis. The Part D plan denied your request 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.Your medical records show your doctor prescribed Diclofenac to treat your primary osteoarthritis involving multiple joints. 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 Diclofenac.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Janumet 1000 milligram/50 milligram tablets prescribed twice daily for diabetes. 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 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.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 cover Janumet at a lower cost-sharing tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 100 milligram tablets prescribed 10 tablets per 30 days for migraine. The Part D Plan denied your request for a tiering exception because the drug at issue was approved as a formulary exception and is not eligible 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.The documentation supports your doctor prescribed Ubrelvy for your migraine disorder. The plan granted a formulary exception for this drug and will cover the drug at the cost sharing level assigned to formulary exceptions. Drugs that are not on the plans formulary and require a formulary exception are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Ubrelvy at a lower cost-sharing tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Praluent, 75 milligrams/milliliter, auto-inject prescribed for hyperlipidemia. The Part D plan denied your request because the drug is already being covered through a Patient Assistance Support Program. Your plan cannot cover a drug that is already covered through a Patient Assistance Support Program. 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 medical record shows the Praluent is prescribed for hyperlipidemia. When you decided to use the Patient Assistance Program, you acknowledged and agreed that the Patient Assistance Support Program will be treated as the primary payer with respect to the medication that you have selected to purchase through the Patient Assistance Support Program. You are currently enrolled from September 15, 2020, through December 31, 2021. Therefore, your plan is not required to cover or provide reimbursement for Praluent, 75 milligrams/milliliter, auto-inject. A physician reviewed your appeal and determined that the plan is not required to cover Praluent because you are enrolled in a Patient Assistance Support Program.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Otezla 30 milligram tablets prescribed twice daily for persistent oral ulcerations. The Part D plan denied your request 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.The submitted documentation shows your doctor prescribed Otezla to treat your persistent oral ulcerations. 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 Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armour Thyroid 60 milligram tablets prescribed for hypothyroidism. The Part D plan denied your request because the drug at issue did not meet the definition of a Part D 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.We determined that the plan is not required to cover the drug because it is not a Food and Drug Administration approved drug. Drugs that are not Food and Drug Administration approved are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets prescribed three time daily for small intestinal bacterial overgrowth. The Part D plan denied your request because this medication is not prescribed for 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. Your medical records show your doctor prescribed Xifaxan to treat your small intestinal bacterial overgrowth. 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 Xifaxan 550 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 200 milligrams prescribed as directed for complex regional pain syndrome. The Part D plan denied the request because it 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. The record shows you were prescribed Modafinil 200 milligrams as directed for complex regional pain syndrome. However, the Medicare approved compendia do not support the use of this drug for your condition. There were no medical records submitted at reconsideration by your prescriber to establish a medically accepted indication. 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 Modafinil because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Propranolol 60 milligram capsules prescribed for essential hypertension. The Part D plan denied your request for a tiering exception because the record does not explain why the alternative drugs in a lower tier would not be effective in treating the enrollees condition. 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. Propranolol 60 milligram capsule is a generic drug on Tier 4 of the plans formulary. The prescriber statement shows the drug is being prescribed to treat the enrollees hypertension. However, the prescriber statement does not explain why the alternative drugs in a lower tier would not be effective in treating the enrollees condition. The plans formulary includes Metoprolol Succinate, which is the same class as Propranolol on Tier 2. You did not address why the Metoprolol Succinate would not work for the enrollee. All generic drugs on lower tiers have not been tried. 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 Propranolol 60 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Cosentyx injection 150 milligrams per milliliter prescribed for chronic psoriasis. The Part D plan denied your request to receive the drug at a lower cost-sharing amount because it is one that is not covered on your plan's formulary or their list of covered drugs. 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. The record shows Cosentyx injection is being prescribed for chronic psoriasis. The Medicare approved compendia supports the use of the requested drug for your condition. However, the drug is not one that is covered on your plan's formulary or their list of covered drugs. You did not indicate that all covered Part D drugs on any tier of the plan's formulary would not be as effective for the enrollee as the requested non-formulary drug, and/or would have adverse effects.The plan is not required to cover the Cosentyx injection at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligram tablet prescribed for hidradenitis suppurativa. The Part D plan denied the request for a non-formulary drug. The plan indicated you did not have a medically accepted indication for this drug. 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 record shows Otezla was prescribed to treat hidradenitis suppurativa. A prescriber statement also indicates the enrollee had tried Cephalexin, Clindamycin, Doxycycline, TMP/SMX, Metronidazole, Spironolactone, Methotrexate, and Rifampin. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Otezla. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyanocobalamin solution prescribed for vitamin B-12 deficiency. The Part D denied your request because this non-formulary drug is excluded from Part D coverage. 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. We determined that the plan is not required to cover Cyanocobalamin because it is a prescription vitamin and mineral product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations, are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclophosphamide 75 milligrams prescribed twice daily for crescentic IgA nephropathy. The Part D plan denied your request because this drug is covered by Medicare Part B. 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 records show you prescribed Cyclophosphamide to treat the enrollees acute kidney injury secondary to for crescentic IgA nephropathy. 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 Cyclophosphamide. Without a medically accepted indication, we cannot determine if the medication is covered under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 7.5 milligrams prescribed twice daily for the treatment of postural orthostatic tachycardia syndrome. The Part D plan denied your request because it 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.Corlanor 7.5 milligrams is requested to treat postural orthostatic tachycardia syndrome, which 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 the enrollees condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined  that the plan is not required to cover Corlanor 7.5 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humira 40milligrams/0.4 milliliter prescribed as directed for sarcoidosis. The Part D plan denied your request because it 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 Humira 40milligrams/0.4 milliliter to treat your sarcoidosis. However, 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. 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 Humira 40milligrams/0.4 milliliter because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha to treat hyperlipidemia. The Part D Plan denied the 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.Repatha is a biologic drug on tier 4 of the Plan's formulary. There are no lower tier biologic drugs of the same type on the Plan's formulary to treat the enrollee's condition.   Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brilinta 90 milligram tablet prescribed twice a day. The Part D plan denied your request for a tiering exception because Brilinta is a Tier 4 medication with no alternate drugs on a lower tier. We received an expedited auto-forwarded 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 Brilinta is a brand drug on Tier 4 of the plans formulary. There are no alternative 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 Brilinta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mag64 prescribed three times a day for hypomagnesiusm and stage four chronic kidney disease. The Part D plan auto-forwarded the case because it did not make a timely decision. 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. We determined that the plan is not required to cover Mag64 because it is a prescription vitamin and mineral product. Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.