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

At issue is a tiering exception request for Risedronate Sodium 35 milligram tablets for osteoporosis. 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.This drug is being provided by the plan under a formulary exception. It is 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Anucort-HC 25 milligram suppositories prescribed for ulcerative (chronic) rectosigmoiditis without complications. The Part D Plan denied your 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 Anucort-HC is not Food and Drug Administration approved. Therefore, the drug cannot be considered a Part D benefit.We determined that the plan is not required to cover Anucort-HC.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle libre 14 day sensor prescribed for diabetes mellitus, type 2. The plan denied you request because medical devices are not covered under Medicare Part D. We received a reconsideration request. We received a 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. We determined that the plan is not required to Freestyle libre 14 day sensor because it is not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. 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: Favorable

At issue is Dextroamphetamine-Amphetamine tablets IR 20mg to treat Attention Deficit Disorder.   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 satisfies the plans coverage criteria.  In the Reconsideration appeal the prescriber submitted medical records which document the diagnosis of Attention Deficit Disorder (ADD).  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is the Accu Check Aviva Plus Strips. The Part D plan denied the request for a quantity limit exception because drugs that can 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. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Therefore, coverage under Part D is excluded for any drug for which payment would be available under Part B. We determined that the Medicare Part D plan is not required to cover the Accu Check Aviva Plus Strips. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for cervicalgia. 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 Lidocaine for cervicalgia. 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 Copaxone 40 milligram subcutaneous syringe prescribed to treat multiple sclerosis. The Part D plan denied the request for a formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. The drug requested is not on the plans formulary. There are no medical records supporting that all alternative drugs on the plans formulary, to treat the same condition, have been tried. A physician reviewed your appeal and determined that the plan is not required to cover Copaxone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Micardis 80 milligrams tablets. The Part D plan denied your request to cover this drug at a lower tier cost. The plan indicated this is a non-formulary approved drug and cannot be provided at a lower tier cost. 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 record shows Micardis was prescribed; however, Micardis is a non-formulary approved drug and is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the Micardis.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sutab 0.225 gram-0.188 gram-1.479 gram tablets. 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.A request was submitted to the prescriber to provide a diagnosis, to address the formulary exception criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tretinoin Cream 0.025%. The Part D plan denied coverage. 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 physician submitted a supporting statement. The prescriber statement indicates that Tretinoin Cream is prescribed to treat scar conditions and fibrosis of skin. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s).A physician reviewed your appeal and determined that the plan is not required to Tretinoin Cream.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vyvanse 20 milligrams daily for attention deficit hyperactivity disorder. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration 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. We asked the prescriber to send us a medical records to support the prescribers statement. The prescriber has not provided 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ketamine HCL powder 100 milligram tablet prescribed as directed for severe pain related to rheumatoid arthritis. The Part D plan denied your request to cover the requested compounded medication. 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. This drug is a compounded drug. Therefore, we reviewed each ingredient individually. The ingredients of the requested drug are: Ketamine powder.Ketamine powder is considered a bulk powder. Bulk powders (i.e., Active Pharmaceutical Ingredients for compounding) do not satisfy the definition of a Part D drug and are not covered by Part D. Therefore, none of the ingredients of the requested drug are Part D drugs. Compounded medications that do not contain at least one ingredient that meets the definition of a Part D drug are excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexium DR 40 milligram capsules prescribed for gastroesophageal reflux disease. 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 indicated Omeprazole, Pantoprazole, and Dexilant were ineffective. The statement did not indicate you could not take the generic form of the drug at issue. 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 Nexium DR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuedexta 20 milligrams prescribed as directed for pseudobulbar affect. The Part D plan denied coverage because the drug was not being used 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 records submitted at the reconsideration level. Your medical records show you were prescribed Nuedexta for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The are no medical records provided to 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 Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nystatin 100,000 units per gram topical powder prescribed for candidiasis of the skin and nail. The Part D plan denied your request for a lower cost tiering exception.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. Nystatin topical powder is a generic drug on Tier 2 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers. If there are no generic drugs of the same type on a lower tier, the drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover the Nystatin topical powder at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulicity 3 milligram/0.5 milliliter injection to treat uncontrolled type II diabetes mellitus. The Part D plan denied your request for a tiering exception. 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. Trulicity is a biologic drug on Tier 3 of the plans formulary. There are no biologic 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 Zolpidem Tartrate 5 milligram tablets prescribed for insomnia. The Part D plan denied coverage because the prior authorization requirements were not met. 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 does not satisfy the plans coverage criteria. The prescribing physician has not sufficiently addressed the plans prior authorization requirements for coverage of this medication. 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 Gleevec 100 milligram tablet prescribed three tablets daily for Philadelphia chromosome positive chronic myeloid leukemia. 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 asked for information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We received the documentation and included it in our review.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 Gleevec 100 milligram tablet.
Appeal type: Prescription Drug
Decision: Favorable

You requested Fentanyl 25 microgram patch prescribed every 72 hours for chronic pain syndrome. 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. The record shows the enrollee is using Hydrocodone-Acetaminophen tablets and Fentanyl patch for chronic pain syndrome since April of 2019. Patient has chronic pain related to cervical and lumbar spinal disease, has a spinal cord stimulator in place, and requires around the clock pain medication. It is being used for a medically accepted indication. We asked the prescriber to send us information in order to satisfy prior authorization criteria. We received that information on March 20, 2021, along with an office note of Dr. Michael Sheth, Board Certified in Pain Management, from March 15, 2021.A physician reviewed your appeal and determined that the prior authorization criteria were satisfied and the plan is required to cover the Fentanyl 25 microgram patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Butrans Patch 20 micrograms/hour weekly to treat the enrollees pain. At issue is a tiering exception request for DRUG to treat the enrollees condition. The Part D plan denied the 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.Butrans Patch is being provided by the plan under a formulary exception. It is 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Oxybutynin chloride 100 milligram tablet prescribed twice daily for urinary incontinence. 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.Oxybutynin chloride 100 milligram tablet is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers. 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 Vascepa 1 gram capsules prescribed to treat coronary arteriosclerosis and diabetes mellitus. 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 record shows you were prescribed Vascepa to treat your condition. 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 Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Cypionate 200 milligram/milliliter injection to treat testicular hypofunction.  The Part D plan denied the request stating the requested drug is not approved by the Food and Drug Administration.  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. Per the compendia, The safety and efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch to treat polyneuropathy and spastic diplegic cerebral palsy. 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 Osphena 60 milligram tablet to treat recurrent urinary tract infections. 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 does 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 a tiering exception request for Eletriptan Hydrobromide 40 milligram tablet to treat the enrollees migraine headaches. The Part D plan denied the 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.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. The drug is placed on Tier 3. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.Our physician reviewers opinion is that non-formulary drugs are not eligible for a tiering exception.