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

At issue is Creon DR 24,000 unit capsule prescribed for exocrine pancreatic insufficiency. The Part D plan denied your request for a 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. Creon DR is a biological product on Tier 3 of the plans formulary. There are no biological products 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 Oxycontin ER 15 milligram tablets  prescribed every 12 hours for chronic pain. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your doctor submitted a statement that Oxycodone was prescribed for your condition. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, your doctor did not provide medical records explaining why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to Oxycodone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 88 micrograms tablet prescribed to take one tablet by mouth every morning for the diagnosis of hypothyroidism. The Part D plan denied your request for a 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.Synthroid is a brand drug on Tier 3 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat your condition have been tried or deemed contraindicated. 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 Armour Thyroid 120 milligram tablet. 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.Armour thyroid has no FDA approved medically accepted indications. Non-FDA approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage. Please note the request for a tiering exception for Armour Thyroid 120 milligram tablet was not reviewed. We cannot consider a tiering exception for a drug that is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80 milligrams per milliliter auto injector prescribed for plaque psoriasis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Caplyta 42 milligram capsules prescribed for major depressive disorder, single episode, unspecified and schizophrenia, unspecified. The Part D plan denied your request for a 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. Caplyta is a brand name drug on Tier 4 of the plans formulary. There are no brand name 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

You requested Belbuca 900 microgram sublingual film, 84 films per 28 days,  prescribed for severe pain. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.The records show you prescribed Belbuca 900 microgram sublingual film three times daily to treat the enrollees severe pain. However, the records do not adequately support why an exception to the plans quantity limit is medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover the Belbuca 900 microgram sublingual film at the requested quantity, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Carisoprodol 350 milligram tablets prescribed for debilitating scoliosis with residual severe chronic musculoskeletal pain. 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. The medical records submitted indicate you are taking the drug at issue for debilitating scoliosis with residual severe chronic musculoskeletal pain. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that the drug was 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 Auryxia one gram tablet.  At initial determination and redetermination the diagnosis of chronic kidney disease with hyperphosphatemia in an enrollee not on dialysis was given. 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.At reconsideration a diagnosis of chronic kidney disease with iron deficiency anemia was given. No medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Nuedexta 20-milligram-10 milligram capsule for pseudobulbar affect. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The prescriber submitted a statement that Nuedexta was prescribed for pseudobulbar affect due to stroke.  Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. 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 Nudexta. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Buprenorphine 20-micrograms/hour patch to treat chronic pain syndrome. 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. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.Our physician reviewer's opinion is that non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Onzetra Xsail 11 milligram per nosepiece nasal inhalation powder prescribed for migraine with aura, not intractable, without status migrainosus. The Part D plan denied the 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.Onzetra Xsail is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives included in the plan would likely not be as effective as the requested drug for this condition, 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

You requested Pennsaid 2% topical solution prescribed to treat the diagnosis of left shoulder tendinitis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows your doctor prescribed Pennsaid 2% topical solution to treat your left shoulder tendinitis. Medical records from date of service 4/12/2021 were provided which support this diagnosis. 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.A physician reviewed your appeal and determined that the plan is not required to cover Pennsaid 2% topical solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doxepin Hydrochloride 10 milligram tablets.  At initial determination and redetermination the diagnosis of G47.00 - insomnia, unspecified was given. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication(s).  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.At reconsideration a diagnosis of G47.00 - insomnia, unspecified was given. The medical records provided by the prescriber indicate a diagnosis of F51.02  History of Adjustment Insomnia. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. The Medicare compendia do not list generic Doxepin HCL, as a medically accepted medication for the provided diagnosis. This medication is also considered a High Risk Medication in the elderly, this enrollee is 83 years old. There is no discussion in the record provided that addresses this issue. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Clobetasol 0.05% shampoo prescribed for seborrheic dermatitis. The Part D plan denied the 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.Clobetasol shampoo is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives included in the plan would likely not be as effective as the requested drug for this condition, 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 coverage Sulfacetamide Sodium 10%-Sulfur 5% topical suspension prescribed for acne vulagrais. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Sulfacetamide Sodium 10%-Sulfur 5% topical suspension is not approved by the Food and Drug Administration. Drugs not approved by the Food and Drug Administration are excluded from Part D coverage. Therefore, the Sulfacetamide Sodium 10%-Sulfur 5% topical suspension 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 Sulfacetamide Sodium 10%-Sulfur 5% topical suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Adderall XR 10 milligram capsule prescribed for fatigue associated with multiple sclerosis. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we 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 prescribers statement shows Adderall XR was prescriber to treat fatigue from multiple sclerosis. 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. A physician reviewed your appeal and determined that the plan is not required to cover Adderall XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Humira (CF) Pen PS-UV-AHS 80-40 subcutaneous injection kit. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Humira has been prescribed for the treatment of granuloma annulare. However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin Extended-Release 20 milligram tablet, a quantity of 60 tablets for 30 days prescribed for pain. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your medical records show your doctor prescribed Oxycontin Extended-Release to treat your pain. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. 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 Oxycontin Extended-Release. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gralise 300 milligram tablets prescribed for the diagnoses of low back pain, degeneration of lumbar intervertebral disc, and lumbar spondylosis and radiculopathy. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows your doctor prescribed Gralise 300 milligram tablets to treat low back pain, degeneration of lumbar intervertebral disc, and lumbar spondylosis and radiculopathy.  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.A physician reviewed your appeal and determined that the plan is not required to cover Gralise 300 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 620 microgram/2.48 milliliter pen injector prescribed for post-menopausal osteoporosis.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. This brand drug is included on Tier 5 of the plans formulary. This Tier is identified as a Specialty Tier. The plan is not required to grant a tier exception for drugs available on their Specialty Tier. Therefore, a tier exception cannot be considered. It is also noted that the prior authorization criteria have not been met. A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception and prior authorization.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Ozempic 2 milligram per 1.5 milliliter subcutaneous injection pen prescribed for type 2 diabetes mellitus and morbid obesity. The Part D plan denied the 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. Ozempic is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand 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 Ozempic at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate HCL 5 milligram tablets prescribed for major depressive disorder, recurrent. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Methylphenidate HCL to treat your major depressive disorder, recurrent. 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 Methylphenidate HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Motegrity 1 milligram tablets prescribed for the diagnosis of gastroparesis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Motegrity 1 milligram tablets to treat gastroparesis. 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 Motegrity 1 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Samsca 15 milligram tablet, a quantity of 12 tablets per 30 days prescribed for hyponatremia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation shows your doctor prescribed Samsca to treat your hyponatremia. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. 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 Samsca. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 5 milligram capsule prescribed twice daily for nausea, vomiting, and anorexia related to short gut syndrome due to Crohn's disease. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The 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.A physician reviewed your appeal and determined that the plan is not required to cover the Dronabinol capsule.