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

You requested a tier exception for Xtampza ER 18 milligrams prescribed for chronic pain. The Part D plan denied your request for a tiering exception because Xtampza ER is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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. The plan shows Xtampza ER is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligram tablets prescribed for interstitial lung disease with nonspecific interstitial pneumonia. 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 Mycophenolate mofetil to treat interstitial lung disease with nonspecific interstitial pneumonia. The Medicare approved compendia do not support the use of Mycophenolate Mofetil for the enrollees 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 Promethazine hydrochloride 25 milligram tablets prescribed as directed. 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. No medical records were provided by the prescriber to support the enrollees 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.A physician reviewed your appeal and determined that the plan is not required to cover Promethazine hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ledipasvir/Sofosbuvir 90/400 milligrams prescribed daily for hepatitis C. The Part D plan denied coverage.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 levelThe medical records show you were prescribed Ledipasvir/Sofosbuvir 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 does not 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 Ledipasvir/Sofosbuvir.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ferrous Sulfate DR 325 milligram tablets prescribed for anemia. 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.Prescription vitamins and mineral products are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Frova 2.5 milligram tablets prescribed as directed for headaches. 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. We also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Frova.A physician reviewed your appeal and  determined that the plan is not required to cover the Frova.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stelara 90 milligrams prescribed as directed to treat moderate to severely active Crohns disease. The Part D plan denied the 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 that Stelara was prescribed to treat your condition. The plan has prior authorization criteria, called step therapy, that require you try and fail, or be intolerant to, another drug before they will cover the requested drug. The records provided do not show that the step therapy criteria have been satisfied. Therefore, the drug is not eligible for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 30 milligrams/1.5 milliliter Pump to treat testicular hypo-function. 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, with supporting medical documentation, 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prodigy no coding test strips prescribed for uncontrolled diabetes. The Part D plan denied coverage because the Prodigy no coding test strips are a medical supply that is specifically excluded from Part D coverage by Medicare law. 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. In this instance, the QIC has determined that coverage cannot be allowed for the Prodigy no coding test strips because the plan does not cover drugs/items excluded from Medicare Part D coverage. Medicare rules state that the definition of a Part D drug includes medical supplies directly associated with the injection of insulin. Test strips, lancets, and needle disposal systems are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. Therefore, the plan is not required to provide coverage for the Prodigy no coding test strips. If the enrollee purchases drugs/items that are excluded, they must pay for them themselves. This decision does not address the medical necessity or appropriateness of the requested item. It only establishes that payment cannot be made under the Medicare Part D benefit.We determined that the plan is not required to cover the Prodigy no coding test strips.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Benlysta Auto-Injector 200 milligram/milliliter to treat systemic lupus erythematosus. The Part D plan denied the 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 does not indicate a laboratory study that confirms auto-antibody positive in the absence of any systemic lupus erythematosus drugs defined as an ANA titer greater than or equal to 1:80 or an anti-dsDNA level greater than or equal to 30 IU/milliliters. The prior authorization requirements were not met. A physician reviewed your appeal and determined that the plan is not required to cover Benlysta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Colesevelam 625 milligram tablets prescribed daily for irritable bowel syndrome with diarrhea and post-cholecystectomy syndrome. 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Colesevelam to treat your irritable bowel syndrome with diarrhea and post-cholecystectomy syndrome. However, the Medicare approved compendia do not support the use of this drug for your conditions. 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 Colesevelam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xadago 100 milligram oral tablet prescribed for Parkinsons 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. 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 Xadago.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vivelle-Dot 0.25 milligrams/day prescribed to treat the enrollees condition. 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.Vivelle-Dot 0.25 milligrams/day is a brand drug that is not on the plans formulary. Non-formulary prescription drugs are not eligible for tiering exceptions. 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 Vivelle-Dot 0.25 milligrams/day at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Indomethacin 25 milligram capsules prescribed as directed for gout. 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. We also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Indomethacin.A physician reviewed your appeal and determined that the plan is not required to cover the Indomethacin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Orencia ClickJect 125 milligrams per milliliters prescribed to treat the diagnosis of moderate to severe rheumatoid arthritis. 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.Orencia ClickJect is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Orencia ClickJect.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vemlidy 25 milligram tablets prescribed as directed for chronic viral hepatitis B without delta agent. The Part D Plan denied your request 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. Vemlidy is a brand name drug on Tier 1 of the plans formulary. Tier 1 drugs are not eligible for a tiering exception because they are already classified as the lowest tier on the plans formulary. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Januvia 100 milligram tablets prescribed for diabetes. The Part D plan denied your request for a tiering exception because Linzess is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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 shows Januvia is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide Suspension 0.5 milligrams per 2 milliliter vial prescribed via nebulizer for mucopurulent chronic bronchitis. 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 record shows the doctor prescribed Budesonide Suspension for mucopurulent chronic bronchitis. However, this drug is eligible for coverage under Medicare Part B. Medicare Part B covers this drug for mucopurulent chronic bronchitis, when used with a nebulizer in the home (or in an assisted living facility). Medicare Part D cannot pay for drugs that are covered by Medicare Part B.We reviewed your appeal and determined that the plan is not required to cover Budesonide Suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levalbuterol Hydrochloride, 1.25 milligrams in 3 milliliter vials, prescribed for the treatment of pulmonary fibrosis, asthma, and chronic respiratory failure. The Part D plan denied the request 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 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 indicates that the Levalbuterol Hydrochloride is being administered to the enrollee via a nebulizer. 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. 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 Levalbuterol Hydrochloride. 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 Cyclophosphamide 50 milligram capsule prescribed for adenocarcinoma of the tail of the pancreas with metastatic disease to the liver. 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.This drug is eligible for coverage under Medicare Part B. Certain oral anticancer drugs are covered under the oral anticancer drug benefit, Social Security Act Section 1861(s)(2)(Q). We determined that the plan is not required to cover Cyclophosphamide 50 milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tradjenta 5 milligram tablets prescribed daily for type II diabetes mellitus. 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. We also researched Medicare systems and reviewed the enrollment data available. Tradjenta 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. 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 Hydrocodone-Homatropine Solution to treat cough. 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. Drugs prescribed for symptomatic relief of cough are excluded from coverage. 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 a tier exception for Myrbetriq ER 50 milligram tablets prescribed for urge incontinence. 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. The plan shows Myrbetriq is a brand name Tier 4 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aciphex 20 milligram twice daily to treat intractable reflux disease. 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.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 Colchicine 0.6 milligram capsules to treat chondrocalcinosis. The Part D plan denied the request. The requested drug is not on the plans formulary. We received an auto-forward 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 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

You requested Crestor 20 milligram tablets prescribed as directed for hyperlipidemia. 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. We also researched Medicare systems and reviewed the enrollment data available.  The requested drug is being provided by your plan under a formulary exception. Crestor 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. A physician reviewed your appeal and determined that non-formulary drugs are not eligible for a tiering exception.