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

You requested Intralipid Emulsion 20% intravenously for moderate protein-calorie malnutrition and malignant neoplasm of stomach with suspected metastatic stage 4 adenocarcinoma of the stomach. The Part D plan denied the request because the information did not include the formulary drugs tried for the treatment of your condition and the results. 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 medical records show your doctor prescribed Intralipid Emulsion 20% for your moderate protein-calorie malnutrition and malignant neoplasm of stomach with suspected metastatic stage 4 adenocarcinoma of the stomach. A Medicare approved compendium does support the use of the requested drug for your condition. However, your doctor did not explain why the requested Intralipid Emulsion 20% is preferred over the plans current covered formulary drugs used to treat your condition. There is no indication your doctor has tried you on covered formulary drugs with documentation of the results, or if the drugs would likely cause adverse events and/or would be less effective than the non-formulary drug Intralipid Emulsion 20%.A physician reviewed your appeal and determined that the plan is not required to cover Intralipid Emulsion 20% because the medical records do not indicate why the non-formulary drug is preferred over current drugs on the plans formulary to treat your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 microgram inhaler prescribed for the chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception because the prescriber did not address all alternatives were tried and failed. 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.Anoro Ellipta is a brand drug on Tier 3 of the plans formulary. The physician submitted a supporting statement. However, the physician did not address why all alternative lower-tier medication on the plans formulary would not work. All brand 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 grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mavyret 100-40 milligram tablets prescribed as directed for Hepatitis C infection. The Part D plan denied coverage because the prior authorization criteria were not met. 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 asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records to show why the enrollee needs this medication. We did receive the documentation requested. The documentation 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 Mavyret.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol 10 microgram vaginal insert prescribed for postmenopausal atrophic vaginitis. 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. 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. 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 Estradiol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Orgovyx 120 milligram tablet prescribed for malignant neoplasm of prostate. The Part D plan denied your request as not medically necessary. 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 asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.Your medical records show your doctor prescribed Orgovyx 120 milligram tablet to treat your malignant neoplasm of prostate. 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 Orgovyx.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick Auto-injector. The Part D plan denied your request for a non-formulary exception. We received an expedited 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 records submitted at the reconsideration level. 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 Topiramate 50 milligrams tablets prescribed twice a day. The Part D plan denied a request for this drug because you did not have a medically accepted indication. 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 physician submitted a supporting statement. The prescriber statement indicates that Topiramate is prescribed for bipolar disorder, as a mood stabilizer. 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 Topiramate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mavyret 100 milligram/40 milligram tablet prescribed for the enrollees chronic hepatitis C virus infection. 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. The documentation supports the drug was prescribed for the enrollees diagnosis of chronic hepatitis C virus infection. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.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 Dilantin 100 milligram capsules prescribed 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.Dilantin 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 Caplyta 42 milligrams capsules. The Part D plan denied a request for this drug. We received an expedited 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 physician submitted a supporting statement. The prescriber statement indicates that Caplyta is prescribed for schizophrenia. The Medicare approved compendium does support the use of the requested drug.However, medical records have not been submitted for review. Therefore, the documentation available 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 Caplyta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine HCl 5 milligrams prescribed for muscle spasms. The Part D plan denied your request because the drug was 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. The submitted documentation indicates your doctor prescribed Cyclobenzaprine HCl for muscle spasms. 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 Nurtec ODT 75 milligram oral tablets prescribed daily for migraine without intractability. The Part D plan denied your request for a tiering 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. Nurtec ODT 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 Nurtec.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Actemra 162 milligram/0.9 milliliter auto injector prescribed for rheumatoid arthritis. 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. 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. 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 Actemra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Entresto 49 milligram-51 milligram tablets prescribed for chronic heart failure. 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 information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Entresto for chronic heart failure. A request for medical records to support the classification of the heart failure was sent to the prescriber. No medical records were submitted. A supporting statement addressed the plans coverage criteria; however, it cannot be determined the drug was prescribed for a medically accepted indication. There is no documentation to support the classification of the enrollees heart failure. 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 Trintellix (Vortioxetine Hydrobromide) 20 milligrams prescribed daily for major depressive disorder. You asked the Part D plan to provide a cost-sharing tiering exception. The plan denied the appeal because there are no brand name drugs of the same type in the lower cost-sharing tiers that treat your 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.Your medical records show your doctor prescribed Trintellix for your major depressive disorder. A Medicare approved compendium supports the use of the requested drug for your condition. However, Trintellix is a brand name drug on Tier 4 of your plan's formulary. There are no brand name drugs of the same type in the lower cost-sharing levels. Therefore, the requested drug is not eligible for a cost-sharing tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Trintellix because there are no brand name drugs of the same type in the lower cost-sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 5 milligram oral capsule prescribed daily for Alzheimers disease with associated appetite suppression. The Part D plan denied your request because the provided diagnosis is a non-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 medical records and prescriber statement show Dronabinol was prescribed to treat advanced Alzheimers disease with significant appetite suppression. However, the Medicare approved compendia do not support the use of this drug for this condition. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is NP Thyroid 30 milligrams. The Part D plan denied the request. 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.Non Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Per the Medicare approved compendia, This drug has not been found by the United States Food and Drug Administration to be safe and effective, and the drug product labeling has not been approved by the Food and Drug Administration. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Nuedexta (Dextromethorphan Hydrobromide/Quinidine Sulfate) 20-10 milligram capsule prescribed two capsules daily for pseudobulbar affect with dementia. The Part D plan denied the request because the drug is not Food and Drug Administration approved for your 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 records submitted at the reconsideration level. Your medical records show your doctor prescribed Nuedexta to treat your pseudobulbar affect with dementia. The Medicare approved compendium American Hospital Formulary Service-Drug Information supports the use of Nuedexta for dementia of the Alzheimers type (Alzheimers disease) or other dementia, as well as amyotrophic lateral sclerosis, multiple sclerosis, Parkinsons syndrome, stroke, and traumatic brain injury. A physician reviewed your appeal and determined that the plan is required to cover Nuedexta because Nuedexta is approved for your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Somatuline Depot 60 milligrams per 0.2 milliliter subcutaneous injection prescribed for a benign thyroid stimulating hormone-secreting pituitary macro-adenoma. 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 Somatuline Depot to treat the enrollees benign thyroid stimulating hormone-secreting pituitary macro-adenoma. 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 Somatuline Depot 60 milligrams per 0.2 milliliter subcutaneous injection.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine Hydrochloric Acid 8 milligram tablet sublingual prescribed for mild to moderate pain. The Part D plan denied your request because the diagnosis provided does not meet the requirements of a Food and Drug Administration 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 Buprenorphine Hydrochloric Acid to treat your mild to moderate pain. However, the Medicare approved compendium does 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 Buprenorphine Hydrochloric Acid because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Afinitor (Everolimus) 10-milligram tablet prescribed for management of a recurrent meningioma. The Part D plan denied the request because the diagnosis provided does not meet the requirements of a Food and Drug Administration 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 your physician prescribed Afinitor for management of a recurrent meningioma. The Medicare approved compendia does not cover this drug for your condition. A physician reviewed the appeal and determined that the plan is not required to cover Afinitor because your diagnosis is not a medically accepted indication per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Betamethasone Dipropionate 0.5% Ointment prescribed for basal cell carcinoma. The Part D plan denied your request because the diagnosis provided does not meet the requirements of a Food and Drug Administration 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 doctor submitted a letter stating that Betamethasone Dipropionate 0.5% Ointment was prescribed to treat chronic eczema. The Medicare approved compendia do support the use of this drug for your condition.  However, the plan requires you tried and failed at least two alternatives before coverage of the requested medication.  This information was not submitted.A physician reviewed your appeal and determined that the plan is not required to cover Betamethasone Dipropionate 0.5% Ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Premarin 0.625 milligrams tablets to treat menopause. The Part D plan denied your request for a tiering exception for this covered drug at a lower cost tier. 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 documentation shows Premarin is a brand drug on Tier 3 of the plans formulary. There are no other drugs of the same type on the lower cost sharing tiers to treat the enrollees condition(s). 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 Premarin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin ER Gastric 1,000 milligrams. The Part D plan denied your request for a non-formulary exception. We received an expedited 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 records submitted at the reconsideration level. 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.