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

At issue is Dofetilide 500 microgram tablets prescribed twice daily for paroxysmal atrial fibrillation. The Part D plan denied your request for a tiering exception because all alternative drugs on lower tiers were not tried and ruled out. 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.Dofetilide is a generic drug on Tier 4 of the plans formulary. Your doctor submitted a supporting statement. The statement said you could not tolerate amiodarone due to respiratory failure. However, the plans formulary includes several generic drugs on lower tiers that have not been tried and failed. Your doctor did not address why all alternatives on the plans formulary would not work for you. All generic drugs on lower tiers have not been tried. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Dofetilide at a lower cost-sharing tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tobramycin 300 milligrams/5 milliliters. 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 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 information submitted at the reconsideration level. The record shows your doctor prescribed Tobramycin 300 milligrams/5 milliliters for your condition. However, this drug is eligible for coverage under Medicare Part B. We determined that the plan is not required to cover Tobramycin 300 milligrams/5 milliliters. Drugs covered under Parts A and B will not be covered under Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligram tablets prescribed twice daily following a lung transplant. The Part D plan denied your request because the drug was prescribed for a non-medically accepted indication, and the drug was payable under Medicare Part B. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Your medical records show your doctor prescribed Mycophenolate Mofetil following your lung transplant for immunosuppressive therapy. 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Midodrine Hydrochloride 10 milligram tablet prescribed for orthostatic hypotension. The Part D plan denied your request for a tiering exception because Midodrine Hydrochloride is a Tier 3 medication with no alternate drugs on a lower tier. We received an expedited auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows Midodrine Hydrochloride is a generic drug on Tier 3 of the plans formulary. There are no alternative drugs of the same type for treating the enrollees condition on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Midodrine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligram tablets prescribed twice daily for retriperitoneal fibrosis. The Part D plan denied your request because the drug was prescribed for a non-medically accepted indication. 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.Your medical records show your doctor prescribed Mycophenolate Mofetil for your diagnosis of retroperitoneal fibrosis. 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipratropium Bromide/Albuterol sulfate Inhalation Solution 0.5 mg/2.5 mg/3 mL prescribed for your diagnosis of chronic obstructive pulmonary disease. 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. The record shows your doctor prescribed Ipratropium Bromide/Albuterol Sulfate Inhalation Solution for your diagnosis of chronic obstructive pulmonary disease. However, this drug is eligible for coverage under Medicare Part B. The drug at issue is used with a nebulizer machine. Supplies that are used in durable medical equipment are covered under Part B.We determined that the plan is not required to cover Ipratropium Bromide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carbidopa/Levodopa 25/100 milligram tablets prescribed every eight hours for Parkinsons dementia. The Part D Plan denied your request for a tiering exception because there were no other alternatives of the same type on a lower tier. 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. Carbidopa/Levodopa is a generic drug on Tier 2 of the plans formulary. The documentation supports that Carbidopa/Levodopa was prescribed for Parkinsons disease. 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.A physician reviewed your appeal and determined that the plan is not required to cover Carbidopa/Levodopa at a lower cost-sharing tier.
Appeal type: Prescription Drug
Decision: Favorable

You requested coverage for Modafinil 200 milligrams for excessive daytime sleepiness disorder. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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. We also researched Medicare systems and reviewed the enrollment data available.In the reconsideration appeal, the prescriber clarified the diagnosis as excessive daytime sleepiness.  Medical records from date of service February 1, 2021, were provided which document that the enrollee has obstructive sleep apnea and excessive daytime sleepiness. The Medicare approved compendia support the use of the requested drug to treat excessive daytime sleepiness due to obstructive sleep apnea.  As well, the enrollee satisfied the plans coverage criteria.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Venclexta 100 milligram tablets prescribed daily for multiple myeloma/amyloidosis. The Part D plan denied your request because the drug was prescribed for a non-medically accepted indication. 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.Your medical records document that your doctor prescribed Venclexta for your diagnosis of Lambda AL amyloidosis with cardiac involvement.   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 Venclexta.
Appeal type: Prescription Drug
Decision: Favorable

You requested Cresemba 186 milligrams prescribed for a diagnosis of aspergillus and other fungal infections. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited auto-forwarded reconsideration request from the plan. 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.Your medical records show your doctor prescribed Cresemba for your diagnosis of aspergillus and other fungal infections due to your immunocompromised state. A review of the Medicare compendia reveal a citation in the medical literature regarding use of this drug for your condition. The Article is: 2016 Dec; 7. Doi: 10.2147/IDR.S102207. Isavuconazole for the treatment of invasive aspergillosis and mucormycosis: current evidence, safety, efficacy, and clinical recommendations. It states Isavuconazole is the first novel triazole agent recently approved by the United States Food and Drug Administration for the treatment of invasive aspergillosis.A physician reviewed your appeal and determined that the plan is required to cover Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig 140 milligrams/milliliter prescribed once monthly for migraines. The Part D plan denied your request for a tiering exception because Aimovig is already in the lowest copay tier for its class. We received an expedited auto-forwarded reconsideration request from the coverage level. 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 records show Aimovig 140 milligrams/milliliter is a brand biologic on Tier 4 of the plans formulary. The prescriber statement shows that Aimovig is being prescribed for migraines. There are no brand biologics of the same type on the lower cost sharing tiers. Therefore, this biologic is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Aimovig 140 milligrams/milliliter at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Benzonatate 100 milligram capsules prescribed three times a day as needed for cough. The Part D plan denied your request because drugs used for the symptomatic relief of cough or colds are excluded from 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 information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The record shows you were prescribed Benzonatate as needed for cough. In review of the Medicare approved compendium, drugs used for the symptomatic relief of cough or colds are excluded from coverage. A physician reviewed your appeal and determined that the plan is not required to cover the Benzonatate at issue because it does not meet the definition of a Part D drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 300 milligrams prescribed four times daily for the diagnoses of dysthymic disorder, generalized anxiety disorder, and post-traumatic stress disorder. The Part D plan denied your request because the drug is non-FDA approved for the reported diagnoses and an exception request, based on medical necessity, cannot be considered as the drug did not meet the definition of a Medicare Part D drug. 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 regulations and your plans information. Your prescriber submitted information requested for a tiering exception that included the diagnoses of generalized anxiety disorder, dysthymic disorder, and post-traumatic stress disorder. These diagnoses were reported as being treated with the requested drug Gabapentin. However, the Medicare approved compendia do not support the use of this drug for your condition. Medicare requires that the drug must be prescribed for a medically accepted indication that is approved by the FDA or supported by one or more citations in Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Gabapentin. A request for a tiering exception cannot be considered for a drug in which the Part D plan is unable to provide coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trokendi XR 50 milligrams prescribed daily for migraines. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited 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. You submitted a supporting statement indicating all medications the enrollee has tried and failed. The medical records show you prescribed Trokendi 50 milligrams to treat migraines, which is a medically accepted indication.However, 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 Trokendi XR 50 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amitiza 24 micrograms prescribed twice daily for chronic idiopathic constipation. The Part D plan denied your request for a tiering exception because the drug is not on the plans formulary. 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. Amitiza 24 micrograms is a brand drug that is not on the plans formulary. The enrollee has been approved for a formulary exception for this medication. An enrollee may not request a tiering exception for a non-formulary prescription drug approved for a non-formulary exception. 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 Amitiza 24 micrograms at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligrams prescribed twice daily for the diagnosis of oral lichen planus. The Part D plan denied your request because the diagnosis provided is not a medically accepted indication for the requested drug. 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. We also researched Medicare approved compendia and the plans formulary.Your medical records show your doctor prescribed Mycophenolate Mofetil 500 mg tablets to treat oral lichen planus.  The Medicare approved compendia do not support the use of this drug for your condition. Medicare law defines those drugs that may be covered under Part D and a covered prescription drug must be used for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested methylphenidate HCL 10 milligrams prescribed once daily. The prescriber initially gave the diagnosis of bipolar disorder to the Plan. Then, the prescriber changed the diagnosis to adjustment disorder in the request for reconsideration. No medical records from the prescriber were submitted to support this change in diagnosis.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 your doctor prescribed methylphenidate HCL to treat your adjustment disorder. 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 Halaven 1 milligram/2 milliliter solution prescribed for malignant neoplasm of mandible. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received an expedited 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 information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Halaven 1 milligram/2 milliliter solution to treat your malignant neoplasm of mandible - ameloblastoma. However, the Medicare approved compendia do not support the use of this drug for your condition. Your presciber did not submit any articles to support a medically accepted indication. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined  that the plan is not required to cover Halaven 1 milligram/2 milliliter solution because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Repatha, 140 milligrams /milliliter, 2 milliters, prescribed daily for hyperlipidemia in atherosclerotic cardiovascular disease. The Part D plan denied your request because the plans prior authorization criteria was 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 information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Repatha to treat your hyperlipidemia in atherosclerotic cardiovascular disease. The Medicare approved compendia do support the use of this drug for your condition. However, the laboratory report submitted shows that your low-density lipoprotein cholesterol  was 93 on August 24, 2020, before starting the drug, and it was 102 on January 11, 2021, after taking the drug. This report shows an increase in your low-density lipoprotein cholesterol after taking the drug. The plan requires that your low-density lipoprotein cholesterol shows a decrease after taking Repatha to indicate effectiveness of the drug. Therefore, the records do not support that prior authorization criterion was met for Repatha.   A physician reviewed your appeal  and has determined that the plan is not required to cover Repatha because the prior authorization criterion was not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trintellix 20 milligram tablet prescribed daily. The Part D plan denied your request for a tiering exception because Trintellix is a Tier 4 medication with no alternate drugs on a lower tier. We received an expedited auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows Trintellix is a brand drug on Tier 4 of the plans formulary. There are no alternative drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Trintellix.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lemon Bioflavonoid (LBC) Complex 200 milligram capsules prescribed twice daily for dizziness. The Part D plan denied your request because Medicare has excluded over-the-counter drug products from Part D coverage. 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 LBC Complex because it is an over-the- counter vitamin and mineral product. Nonprescription, or over-the-counter drugs, 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 Diclofenac Sodium 3% Gel prescribed for your diagnosis of spondylosis without radiculopathy. 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.Your medical records show your doctor prescribed Diclofenac Sodium to treat your spondylosis. 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 Diclofenac Sodium.