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

At issue is Amphetamine-Dextroamphetamine extended-release 25 milligram capsules prescribed twice daily for attention deficit disorder. 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. Amphetamine-Dextroamphetamine is a generic drug on Tier 4 of the plans formulary. The prescriber statement shows the enrollee was not an appropriate canidate for Modinafil and requires Amphetamine-Dextroamphetamine to treat attention deficit disorder. However, 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 grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tymlos Solution Pen Injector prescribed for osteoporosis. The Part D plan denied the request. 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 Medicare approved compendia. Medicare approved compendia does not support the use of this medication for the diagnosis submitted. Therefore, it is ineligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover Tymos Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyndamax 61 milligrams capsule prescribed for amyloidosis, atrial fibrillation, and shortness of breath. The Part D plan denied your request to cover this drug at a lower tier cost. The plan indicated this is a non-formulary drug and cannot be provided at a lower tier cost. We received a 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. The record shows Vyndamax was prescribed; however, Vyndamax is a non-formulary approved drug and is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the Vyndamax.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic .25-.5 milligram dose pen to treat type 2 diabetes mellitus. 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 record shows you are requesting Ozempic .25-.5 milligram dose pen at a quantity of 224 day supply. According to the plan, this drug is a specialty drug and is covered as a recurring 30 day supply, and up to a maximum of a recurring 90 day supply. Therefore, an exception to the plans coverage criteria is not supported. We have determined the plan is not required to cover Ozempic above the maximum quantity limit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipratropium Bromide 0.2% inhalation solution prescribed for moderate persistent asthma. 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows Ipratropium Bromide inhalation solution was prescribed for moderate persistent asthma. However, this drug is eligible for coverage under Medicare Part B. Inhalation medication used in a nebulizer in an enrollees home are eligible for coverage under Medicare Part B.We determined that the plan is not required to cover Ipratropium Bromide solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregablin 100 milligrams capsule, quantity 90 per 18 days prescribed for chronic diabetic peripheral neuropathy. The Part D plan denied coverage due to prior authorization requirements. We received a 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 records submitted at the reconsideration level. The physician submitted a supporting statement. The prescriber statement indicates the physician had prescribed Pregablin to treat diabetic peripheral neuropathy, postherpetic neuralgia, and cancer-related neuropathic pain, and that the enrollee has tried and failed other alternatives. However, the documentation submitted provides conflicting information. Therefore, the documentation available does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Pregablin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide three milligrams prescribed three capsules daily for microscopic colitis. The Part D Plan denied your request for a tiering exception because there was no evidence that the enrollee had tried one of the drugs on a lower 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. Budesonide is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the Plan, or why the Plans lower tiered drugs would likely not be as effective as the requested drug.  Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucala 100 milligrams per milliliter auto injector prescribed for the treatment of severe persistent asthma. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Nucala as an off-formulary exception.The Medicare approved compendia support the use of the requested drug for the enrollees condition. However, the submitted medical records do not sufficiently address why the all of the alternative drugs that are included in the plans formulary to treat the enrollees condition have not been tried, or are contraindicated. Therefore, the plan will not cover the Nucala as an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ambrisentan 5 milligrams for Raynauds disease. 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 the drug for Raynauds disease. 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 Ambrisentan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz XR 11 milligrams prescribed as directed for alopecia areata. 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 Xeljanz XR 11 milligrams to treat your alopecia areata. 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 the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Asenapine Maleate 5 milligram tablet sublingual to treat major depressive disorder with significant insomnia. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received a 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. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover Asenapine Maleate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Emgality 120 milligram/milliliter pen prescribed for the enrollees migraine disorder. 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 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 records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of migraine disorder. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Ointment 5 percent prescribed daily for muscle spasm. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a 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. The record shows you were prescribed Lidocaine Ointment for muscle spasm. In review of the Medicare approved compendia, muscle spasm is not a medically accepted indication for Lidocaine Ointment. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Lidocaine Ointment at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Toprol XL 25 milligrams tablet. 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. Toprol XL is a brand drug on Tier 3 of the plans formulary. The prescriber has not indicated why other 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, a tiering exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Toprol XL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxymorphone HCl ER 40 milligram tablets prescribed for bilateral post-traumatic osteoarthritis of the knee. 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. Your physician submitted a supporting statement. The supporting statement did not indicate 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 Oxymorphone HCl ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fentanyl, 50 microgram per hour transdermal patches with a quantity of 15 patches per 30 days. The Part D plan denied your request because the amount of Fentanyl prescribed exceeded the plans quantity limits of how much opioid an enrollee can have on hand. Additionally, the submitted documentation did not include the necessary information to support the requested quantity of medication. 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 also researched Medicare systems and reviewed the enrollment data available. The prescribing physician submitted a progress note from an office visit at reconsideration that shows the enrollee is receiving Fentanyl patches for lower back pain, scoliosis, and neck pain. However, these conditions do not meet the requirements outlined in the plan to exceed the quantity limits of opioid allowed on hand. Therefore, an exception to the quantity limit cannot be granted. A physician reviewed your appeal and determined that the plan is not required to cover the Fentanyl patches, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Desvenlafaxine Succinate 25 milligrams prescribed daily for unspecified bipolar disorder. The Part D plan denied your request for a medication that requires prior authorization 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Desvenlafaxine Succinate 25 milligrams to treat your unspecified bipolar disorder. However, 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 Desvenlafaxine Succinate 25 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol 180 milligram tablets prescribed for the diagnosis of pure hypercholesterolemia, unspecified. 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 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. There are multiple drugs listed in the formulary that the prescriber did not address. Our Physician Reviewers opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500 milligram tablets prescribed daily for granulomatosis with polyangiitis. The Part D plan denied your request. We received a 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. The record shows you were prescribed Mycophenolate Mofetil for granulomatosis with polyangiitis. In review of the Medicare approved compendia, granulomatosis with polyangiitis is not a medically accepted indication for Mycophenolate Mofetil. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Mycophenolate Mofetil at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary request for Anoro Ellipta 62.5-25 microgram inhalation prescribed daily for chronic cough. The Part D plan denied your request. We received a 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. The prescribers statement clarifies that you were prescribed Anoro Ellipta for chronic cough. In review of the Medicare approved compendia, chronic cough is not a medically accepted indication for Anoro Ellipta. Therefore, it does not meet the definition of a Part D drug and a formulary exception cannot be granted. The plan is not required to cover the Anoro Ellipta at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temazepam 30 milligram tablets prescribed as 30 tablets for 30 days for insomnia. The Part D plan denied the request. 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 Medicare approved compendia. Medicare approved compendia supports this drug for short term insomnia generally of 7-10 days duration. It is also to be used or avoided in older adults as potentially inappropriate. There was no indication that medication with less risk in older adults was tried or supporting evidence of why the tablets are being prescribed for longer than the 7-10 day duration recommendation. Therefore, it is ineligible for overage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover Temazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Entresto 24 milligram-26 milligram tablet prescribed twice daily to treat the enrollees condition. The Part D plan denied the request. 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 Entresto is being prescribed for your atherosclerotic heart disease. Entresto 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 to treat the same condition. 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 a tiering exception request for Levemir Flextouch 100 units/milliliter  to treat diabetes mellitus. 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.Levemir Flextouch is a brand drug on Tier 3 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  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 Mycophenolate Mofetil 100 milligram tablets prescribed daily for fibromyalgia. The Part D plan denied your request. We received a 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. The record shows you were prescribed Mycophenolate Mofetil for fibromyalgia. In review of the Medicare approved compendia, fibromyalgia is not a medically accepted indication for Mycophenolate Mofetil. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Mycophenolate Mofetil at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Butalbital/acetaminophen/caffeine 50 milligrams/325 milligrams/40 milligrams tablets prescribed as directed for chronic migraine without aura, not intractable, without status migrainosus. The Part D plan denied your request because it does not meet the criteria of 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Butalbital/acetaminophen/caffeine 50 milligrams/325 milligrams/40 milligrams tablets to treat your chronic migraine without aura, not intractable, without status migrainosus. However, 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 Butalbital/acetaminophen/caffeine 50 milligrams/325 milligrams/40 milligrams tablets because it was not prescribed for a medically accepted indication.