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

You requested Oxandrolone 2.5 milligram tablets prescribed for failure to thrive post-operatively. The Part D plan denied your request because drugs prescribed to treat weight loss do not meet the definition of Part D 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 determined that the plan is not required to cover Oxandrolone because it was prescribed to treat weight loss. Drugs to treat anorexia, weight loss, or weight gain 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 Tacrolimus 1 milligram prescribed twice daily following a kidney transplant. 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 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 Tacrolimus 1 milligram after a kidney transplant. The record shows that you received a kidney transplant on December 6, 2007. According to Medicare enrollment records, you were entitled to Medicare Part A coverage on November 1, 2007. Medicare law excludes coverage for any drug under the Part D program for which payment would be available under Parts A or B. Coverage is available under Medicare Part B for prescription drugs used in immunosuppressive therapy furnished to an enrollee that was covered under Medicare Part A at the time of the transplant. You were covered under Medicare Part A at the time of the transplant. 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 Tacrolimus 1 milligram 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 Tacrolimus 1 milligram to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Donepezil 23 milligram tablets prescribed as directed for memory support post-concussion with loss of consciousness and traumatic brain injury. The Part D plan denied your request for a formulary exception 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Donepezil 23 milligram tablets to treat your memory support post-concussion with loss of consciousness and traumatic brain injury. 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 Donepezil 23 milligram tablets because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Carisoprodol 250 milligram tablets prescribed as directed for chronic muscle spasms and pain. 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. The documentation shows the doctor prescribed Carisoprodol for chronic muscle spasms and pain. 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 Carisoprodol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Harvoni 90-400 milligram tablets prescribed daily to treat the enrollees condition. 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 auto-forwarded reconsideration request from the plan.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested.The records show Harvoni 90-400 milligram tablets were prescribed. However, the documentation submitted does not include the enrollees condition and 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 Harvoni 90-400 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pradaxa, 110 milligram tablets prescribed for paroxysmal atrial fibrillation. The Part D plan denied your request for a lower-cost tiering exception because the medication is not included on the Part D plans formulary. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.Pradaxa is not included on the plans formulary. The plan does not grant tiering exceptions to non-formulary drugs. Therefore, the Pradaxa is not eligible for coverage at a lower-cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Demeclocycline HCl 300 milligram tablets prescribed twice daily to treat the enrollees condition.   The Part D plan denied the 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 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.Demeclocycline HCl is a generic drug on Tier 4 of the plans formulary. There are no generic 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 Febuxostat 40 milligrams prescribed as directed for hyperuricemia. 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. Your medical records show you were prescribed Febuxostat to treat your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided do not show the coverage criteria have 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 Febuxostat.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexium 40 milligram capsules prescribed daily for a hiatal hernia. 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. The requested drug is being provided by your plan under a formulary exception. Nexium 40 milligram capsules are not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.  A physician reviewed your appeal and determined that the plan is not required to cover Nexium 40 milligram capsules because non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Synthroid 100 microgram tablets. 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 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. Synthroid 100 microgram tablet is a brand drug on Tier 3 of the plans formulary.A request for medical records and a prescribers statement was submitted to the prescriber but there was no response. There is no indication 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.  Our Physician Reviewers opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patches prescribed as directed for chronic low back pain from lumbar stenosis. 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 medical records show the doctor prescribed Lidocaine for chronic low back pain from lumbar stenosis. 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate HCL 10 milligrams prescribed daily for major depressive disorder. 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 Methylphenidate HCL 10 milligrams daily to treat your major depressive disorder. 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 10 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symbicort 80-4.5 microgram inhaler provided to you while in the hospital. The Part D plan denied your request for reimbursement. 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 plan denied your request for reimbursement because a valid National Drug Code was not provided for the Symbicort 80-4.5 microgram inhaler. We verified the National Drug Code number that you provided with the Food and Drug Administration. The number is invalid and therefore, the drug  is not eligible for coverage under Medicare Part D.  We determined the plan is not required to cover and provide reimbursement for the Symbicort 80-4.5 microgram inhaler.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram per milliliter injection to treat hyperlipidemia. 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 was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the Plans prior authorization criteria. A response from the prescriber was not received. The documentation does not satisfy the plans coverage criteria.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 Morphine Sulfate ER 30 milligram tablets prescribed for chronic pain due to degeneration of intervertebral disc. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of chronic pain due to degeneration of intervertebral disc. 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

You requested Butalbital-Acetaminophen-Caffeine 50-325-40 milligrams. The Part D plan denied your request because there was insufficient documentation submitted. We received an auto-forwarded reconsideration request from the coverage level. 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 the prescriber to send us a prescribers statement and medical records. However, we did not receive the documentation.We determined that the plan is not required to cover the drug. Without medical documentation from the physician, we cannot determine if this drug is medically indicated.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick Solution Auto-Injection to treat hyperlipidemia. 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 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 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 or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewers opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 100 milligram tablets prescribed daily for migraines. 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. The requested drug is being provided by your plan under a formulary exception. Ubrelvy 100 milligram tablets are not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.    A physician reviewed your appeal and determined that the plan is not required to cover Ubrelvy 100 milligram tablets because non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carafate 100 milligrams/milliliter solution prescribed for gastroesophageal reflux. The Part D plan denied your request for a tiering exception because the drug at issue was covered as a formulary exception and was 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.Carafate is a non-formulary drug. Non-formulary drugs 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 Amitiza 24 microgram capsules prescribed daily 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 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.Amitiza 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 for Eliquis 2.5 milligram tablets prescribed for the diagnosis of paroxysmal atrial fibrillation. The Part D Plan denied your request. We received an expedited 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.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. 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 Tremfya 100 milligrams per milliliter prescribed once per 28 days then every eight weeks 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. The records do not show why the enrollee cannot take other drugs on the plans formulary for their condition.A physician reviewed your appeal and determined that the plan is not required to cover Tremfya.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is  Perforomist 20 milligram/2 milliliter nebulizer solution to treat pulmonary fibrosis.  Medical records were provided.  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 Nuedexta 10-20 milligram tablets prescribed for pseudobulbar affect. 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. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The plan requires that the drug be prescribed by a neurologist. The documentation provided does not show the criterion has been satisfied.A physician reviewed your appeal and determined that the plan is not required to cover Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligrams per milliliter pen injector to treat Heterozygous Familial Hypercholesterolemia (HeFH). 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan would likely cause harm or not be as effective as the requested drug. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.