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

You requested Sildenafil citrate 100 milligram oral tablet prescribed as needed for erectile dysfunction. The Part D plan denied your request because the requested drug is not covered under Medicare Part D. 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 Sildenafil. Drugs prescribed for the treatment of sexual or erectile dysfunction 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 Neupro 4 milligram 24 hour patch prescribed daily for severe restless leg sydrome. 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. Neupro is a brand drug on Tier 4 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

You requested Methylphenidate HCL 10 milligram tablets prescribed as directed for fatigue related to multiple sclerosis. The Part D plan denied your request because the provided diagnosis does not meet the criteria of 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 Methylphenidate HCL to treat your fatigue related to multiple sclerosis. 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. 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 Methylphenidate HCL because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 milligram oral tablet prescribed daily for type II diabetes mellitus with diabetic polyneuropathy. 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. Jardiance 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 Otezla prescribed to treat psoriasis. 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. On reconsideration the prescriber submitted a supporting Letter of Medical Necessity. The statement shows Otezla was prescribed to treat a history of psoriasis that began on bilateral hands and has been resistant to traditional therapy including topical steroids. The enrollee also has developed plaque psoriasis on the scalp. The enrollee has previously tried alternative therapies such as topical steroids and intralesional steroids with short term relief. However, the prescriber does not include what drugs were tried specifically. The record does not confirm all drugs on the plans formulary were tried.A physician reviewed your appeal and determined that the plan is not required to cover Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta ER 50 milligram tablets. 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 submitted documentation does not include medical records or evidence of a prescribed diagnosis. A request was submitted for medical records and a prescriber statement to address formulary alternatives. No records were submitted. Therefore, it cannot be determined the drug was prescribed for a medically-accepted indication. 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 Nucynta ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Opsumit 10 milligram tablet to treat the diagnosis of pulmonary arterial hypertension. 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 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 records show the requested drug is being prescribed to treat the enrollees condition. No medical records are included with the file. However, Opsumit is not on the plans formulary. 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. Therefore, an exception to the plans coverage criteria is not supported.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 Omnaris Spray prescribed for allergy treatment. 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 Omnaris Spray for your allergy treatment. There are no brand name drugs of the same type in 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 Omnaris Spray because the requested drug is not eligible for a cost-sharing tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 10 milligram tablets prescribed daily for type II diabetes mellitus. The Part D plan denied your request for a tiering exception. 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. Jardiance 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 Cinacalcet HCL 30 mg tablets to treat secondary hyperparathyroidism in an enrollee with chronic kidney disease who is not on dialysis.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix vial kit. 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. Shingrix is a brand drug on Tier 4 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

You requested Entresto 24-26 milligram tablet prescribed two times daily for cardiomyopathy. The Part D plan denied your request for unknown reasons. 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. The case file was requested but not received. A physician reviewed your appeal and determined that the plan is not required to cover the Entresto. There is insufficient documentation to determine the requirements of the plan or if the medicine is medically necessary.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Prolia 60 milligram per milliliter syringe prescribed daily for osteoporosis. The Part D plan denied your request for a tiering exception because Prolia is a brand name Tier 4 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 record shows Prolia is being prescribed for osteoporosis. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Prolia 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: Favorable

At issue is Xifaxan 550 milligram tablets prescribed as two tablets daily for chronic hepatic encephalopathy. At coverage determination and redetermination a diagnosis of irritable bowel syndrome with diarrhea was used to decide unfavorably. The Part D plan denied coverage because there was insufficient documentation to determine if the prior authorization criteria were 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 records submitted at the reconsideration level. The medical records show the enrollee has chronic hepatic encephalopathy. The medical records submitted of August 24, 2020, and December 14, 2020, along with a prescriber letter of March 8, 2021 clarify the diagnosis and demonstrate that the drug requested has successfully prevented further recurrences of hepatic encephalopathy. The Medicare approved compendia do support the use of this drug for the enrollees condition. In addition, the medical records state the enrollees hepatic encephalopathy was clinically stable, with significantly improved laboratory values, while taking Xifaxan. The documentation provided shows the enrollee has satisfied the plan's coverage criteria for an enrollee with hepatic encephalopathy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vemlidy 25 milligram tablets for a history of osteoporosis. 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 diagnosis 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 Vemlidy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone Hydrochloride 100 milligrams per 5 milliliters oral concentrate. The Part D Plan denied your request for a lower-cost tiering exception because the medication is not included on the plans formulary. 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. A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.Oxycodone Hydrochloride oral concentrate is not included in the plans formulary. The plan has agreed to cover this non-formulary drug at a cost sharing level assigned to non-formulary drugs. The plan does not grant tiering exceptions to non-formulary drugs. Therefore, the Oxycodone Hydrochloride oral concentrate is not eligible for coverage at a lower-cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha SureClick 140 milligrams/milliliter for subcutaneous injection prescribed as directed for hyperlipidemia. The Part D Plan denied your request for a tiering exception because there were no biologic drugs of the same type on the lower cost sharing tiers. 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.Repatha SureClick is a biologic drug on Tier 4 of the plans formulary. There are no biologic 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 Ipratropium-Albuterol Nebulizer Solution 0.5/2.5 (3)/milligram/3 milliliters prescribed for 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 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. We determined that the drug is eligible for Part B coverage. Therefore, the drug cannot be considered for payment under the Part D benefit.Your medical records show your doctor prescribed Ipratropium-Albuterol to treat your condition. However, the drug is administered through your nebulizer at home and therefore it is covered under Part B.A physician reviewed your appeal and determined that the plan is not required to reimburse the Ipratropium-Albuterol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Contrave Extended Release 8/90 milligram tablets. The Part D plan denied the request. We received a reconsideration request. 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 drug that is requested, Contrave, is a weight loss medication. Medications used for anorexia, weight loss, or weight gain are excluded from Medicare Part D drug benefits.Our Physician Reviewers opinion is that the plan is not required to cover Contrave.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tramadol HCl 50 milligram tablets (120/30) for degenerative joint disease. The Part D plan denied your request because an initial seven-day opioid fill was not completed. 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. The record indicates you are requesting reimbursement for the drug at issue. Your medical records indicate the drug was prescribed for your degenerative joint disease. The plan denied payment for the drug at issue as your records do not support you have completed an initial seven-day fill for the medication. Part D plans are expected to implement a hard safety edit to limit initial dispensing to a supply of seven days or less. A hard safety edit stops the pharmacy from processing a prescription until an override is entered or authorized by the plan.We determined that the plan is not required to reimburse you for the Tramadol HCl.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Aimovig injectable prescribed for migraines. We received a reconsideration request from the plan. We performed an independent and de novo review. We reviewed all documentation submitted. Aimovig is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary. Therefore, this drug is not eligible for a tiering exception.Our Physician Reviewers opinion is that the plan is not required to cover Aimovig at a lower tier cost.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone HCl 30 milligram tablets prescribed five tablets daily for the enrollees unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder. The Part D plan denied coverage because the maximum opioid quantity limit was exceeded. 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 documentation supports the drug was prescribed for the enrollees diagnosis of unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder. The prescriber is requesting a daily maximum morphine equivalent dose greater than 200 milligrams per day. The prescriber is requesting 225 milligrams per day. There were no medical records submitted to document the dosage requested is necessary to manage the enrollees pain. An exception to the daily maximum morphine equivalent criteria has not been met.A physician reviewed your appeal and determined that the requested drug is not eligible for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Prednisolone Sodium Phosphate 1 % eye drops 10 milliliters for after cataract surgery care. 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. The drug code submitted is not a valid National Drug Code. 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 reimburse payment of the Prednisolone Sodium Phosphate 1 % eye drops.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nystop powder. The Part D plan denied your request for a tiering exception for this drug at a lower cost tier. 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 shows Nystop is a generic drug on Tier 3 of the plans formulary. There are no other drugs of the same type on the lower cost sharing tiers to treat the enrollees condition(s). Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spiriva Respimat Aerosol Solution 2.5 microgram/actuation to treat chronic obstructive pulmonary disease. The Part D plan denied the request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. 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. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewers opinion is that formulary exception criteria are not met.