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

At issue is Entresto 24-26 milligrams prescribed for chronic systolic heart failure. You asked the Part D plan to provide a cost-sharing tiering exception. The plan denied the appeal because there are no brand name drugs of the same type in the lower cost-sharing tiers that treat your condition. 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 Entresto for your chronic systolic heart failure. A Medicare approved compendium supports the use of the requested drug for your condition. Entresto is a brand name drug on Tier 3 of your plan's formulary. 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 cost-sharing tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Entresto because there are no brand name drugs of the same type in the lower cost-sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Saxenda 18 milligrams/3 milliliters injection pen prescribed for obesity. The Part D plan denied your request because this type of drug is excluded from Part D coverage. 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 determined that the plan is not required to cover Saxenda because drugs used for weight loss 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

At issue is Simponi 50 milligram injection to treat sarcoidosis of lung. The Part D plan denied your request for an off-formulary exception because the requested 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Simponi 50 milligram injection to treat your sarcoidosis of lung. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not support the use of this drug for your condition.  Per Medicare rules, drugs that are not prescribed for a medically accepted indication are not eligible for an off-formulary exception. 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 grant your request for an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dexilant 60 milligram tablet prescribed daily for gastroesophageal reflux disease. 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 your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. . We received the prescriber statement and included it in our review. However, there were no medical records submitted.A physician reviewed your appeal and determined that the plan is not required to cover Dexilant.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 20 milligram tablets prescribed daily for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Xarelto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dicyclomine 20 milligrams prescribed as directed for symptoms associated with irritable bowel syndrome. The Part D plan denied coverage because the plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level. Your medical records show you were prescribed Dicyclomine 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 the Dicyclomine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acitretin 10 milligram capsules to treat Hailey-Hailey disease. The Part D plan denied your request. 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 regulations and Medicare approved compendia. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees condition. The drug is not approved by the food and drug administration to treat the diagnoses submitted. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our Physician Reviewers opinion is that the plan is not required to cover Acitretin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Tetrabenazine 12.5 milligram tablets prescribed for tardive dyskinesia. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes any information submitted at the reconsideration level. Tetrabenazine is a generic drug on Tier 5, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the specialty tier from the tiering exception process. 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 Tetrabenazine. A tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Epclusa 400-100 milligram prescribed for chronic viral hepatitis C. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The medical records show you prescribed Epclusa to treat the enrollees hepatitis C, chronic, Genotype 2 without cirrhosis or with compensated cirrhosis. The Medicare approved compendia do support the use of this drug for this condition. The plan requires prior authorization be met before they will cover the requested drug. The records indicate that enrollees chronic viral hepatitis C is genotype 2 with RNA levels of 101,000 international units per milliliter. The records also indicate that the enrollee does not have cirrhosis and is treatment naive. Furthermore, the family nurse practitioner prescribed the medication while consulting with a gastroenterologist and clinical pharmacy specialist. The documentation provided does show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Epclusa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 1 milligram prescribed for post-kidney transplant. The Part D Plan denied the request because immunosuppressant drugs are covered under Part B if they are used for transplant related purposes and if Medicare covered your transplant. 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.We determined that the drug is eligible for Part B coverage. The beneficiary had a Medicare-covered transplant on November 24, 2012. Therefore, the drug can be considered for payment under the Part B benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nitrofurantoin MCR 50 milligram capsules to treat a urinary tract infection. 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 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 Nitrofurantoin MCR. A physician reviewed your appeal and determined that the plan is not required to cover Nitrofurantoin MCR because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligram/2 milliliter injection prescribed for asthma. 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. Your physician submitted a supporting statement. The supporting statement did not indicate all formulary alternatives would be ineffective. 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 Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Praluent 75 milligram/milliliter pen injection prescribed for atherosclerotic cardiovascular disease. 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. Your physician submitted a supporting statement. The supporting statement did not indicate all formulary alternatives would be ineffective. 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 Praluent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500 mg tablets.  At initial determination and redetermination the diagnoses of - other specified disorders involving the immune mechanism, not elsewhere classified, antisynthetase syndrome with lung involvement, Respiratory disorders in diseases classified elsewhere, other specified interstitial pulmonary diseases, antisynthetase lung disease, rheumatalogic lung disease were given. The Part D plan denied the request stating that the provided diagnoses are not-medically accepted indications.  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 interstitial lung disease with auto-immune features (IPAF - interstitial pneumonia with autoimmune features) marked by both fibrosis and lymphocytic inflammation on broncho-alveolar lavage was given. 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: Favorable

At issue is Pregabalin 150 milligrams to be given twice a day for chronic pain syndrome and fibromyalgia. 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 records submitted at the reconsideration level.Pregabalin is being requested to treat the enrollees condition. The Medicare approved compendia support the use of this drug for this condition. The plan requires the drug to be prescribed for the management of fibromyalgia or management of neuropathic pain associated with spinal cord injury. The documentation provided shows the plan's prior approval coverage criteria have been satisfied.A physician reviewed your appeal and determined that the plan is required to cover the Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cinacalcet HCl 30 milligram tablets prescribed for secondary hyperparathyroidism not chronic renal disease and dialysis related. 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 submitted documentation indicates your doctor prescribed Cinacalcet HCl for secondary hyperparathyroidism in an enrollee not on dialysis. 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 Oxybutynin Chloride 10 milligram tablets prescribed for urinary incontinence. The Part D plan denied your request for a tiering exception because the prescriber did not address all alternatives were tried and failed. 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 is a generic drug on Tier 3 of the plans formulary. The physician submitted a supporting statement. The statement said Toviaz and Myrbetriq has been tried and failed. However, the physician did not address why all alternative lower-tier medication on the plans formulary would not work. 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 grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 2 milligram tablet prescribed for hyperlipidemia. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Livalo 2 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine-prilocaine cream prescribed daily for dialysis for end stage renal disease. The Part D plan denied your request because the drug is eligible for Part B coverage and is excluded from Part D coverage. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. We determined that the plan is not required to cover the Lidocaine-prilocaine cream. Drugs which are eligible for Part B coverage are excluded from Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is reimbursement for a Herpes Zoster Vaccine and administration. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. The information provided includes the invoice for the service and drug with the enrollees receipt. Our Physician Reviewers opinion is that the plan is required to reimburse payment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is shingrix 50 micrograms prescribed for shingles vaccination. The Part D plan denied the request for additional reimbursement. We received a request to reconsider the appeal. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The record shows you purchased the vaccine from a network pharmacy. The plan submitted documentation that shows you were still in the deductible stage for part of the cost for this drug and entered the initial stage for the remaining amount. Therefore, the drug was paid correctly to the pharmacy and no further reimbursement is required by the plan. In addition, the record shows you received the vaccine at a physicians office. Payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or provider's office. You submitted documentation to the plan that includes a copy of an itemized bill. However, the record does not include proof of payment such as an itemized statement showing the bill was paid in full. We determined that the plan is not required to reimburse you for the vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Esomeprazole 20 milligram capsules prescribed for peptic ulcer disease. The Part D Plan denied your request for a tiering exception because the submitted documentation did not explain why the plans alternative drugs in lower tiers would not work just as well. 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. Medical records were requested and received from your physician during this review, but not received.Esomeprazole is a generic drug on Tier 4 of the plans formulary. The submitted medical records from the physician do not sufficiently address why all of the generic drugs of the same type on the lower tiers of the plans formulary to treat the enrollees condition have been tried and failed, or are contraindicated. Therefore, the plan cannot grant a lower cost tiering exception for the Esomeprazole.A physician reviewed your appeal and determined that the Esomeprazole is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amphetamine-Dextroamphetamine ER 30 milligram capsule to treat major depressive disorder.  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.