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

At issue is Corlanor tablets prescribed twice a day for sinus tachycardia. The Part D plan denied a request for this drug because you did not have 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 Corlanor was prescribed to treat sinus tachycardia. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dalfampridine Extended Release 10 milligrams prescribed daily for episodic cerebellar ataxia. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization requirements be met 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 information submitted at the reconsideration level. Your medical records show your doctor prescribed Dalfampridine Extended Release to treat your episodic cerebellar ataxia. The documentation does not satisfy the plans coverage criteria. Additionally, the Medicare approved compendia does not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Dalfampridine Extended Release.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 100 milligrams tablet prescribed for acute treatment of migraine headache. The Part D plan denied your request to cover this drug at a lower tier cost. The plan indicated this is an approved 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 Ubrelvy was prescribed; however, Ubrelvy is approved by the plan as a non-formulary 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 Ubrelvy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathioprine 50 milligrams tablets prescribed for plaque psoriasis and psoriatic arthritis. The Part D plan denied coverage. 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 Azathioprine was prescribed to treat plaque psoriasis and psoriatic arthritis. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to cover Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 50 milligram tablets prescribed two times daily for multiple sclerosis related fatigue. 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 Armodafinil for multiple sclerosis related fatigue. 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

You requested Durezol 0.05 percent emulsion prescribed three times daily for cystoid macular edema. The Part D plan denied your request for a formulary exception 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Durezol 0.05 percent emulsion to treat your cystoid macular edema. 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 Durezol 0.05 percent emulsion tablets because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fioricet/Codeine capsule prescribed for headache. The Part D plan denied your request to cover this drug at a lower tier cost. The plan indicated this is an approved 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 Fioricet/Codeine was prescribed; however, Fioricet/Codeine 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 Fioricet/Codeine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Neupro 3 milligram patch prescribed daily for restless leg syndrome. The Part D plan denied your request for a tiering exception because there were no brand 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 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.Neupro 3 milligram patch 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.Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha, 140 milligrams per milliliter solution auto-injector prescribed for the following conditions: hyperlipidemia, unspecified; abnormal findings on diagnostic imaging of heart and coronary circulation; and disorder of arteries and arterioles, unspecified. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Repatha as an off-formulary exception.The Medicare approved compendia support the use of the requested drug for the noted conditions. However, the submitted documentation does not sufficiently address why all of the alternative drugs listed in the plans formulary to treat the enrollees conditions have not been tried, or are contraindicated. Therefore, the plan is not required to cover the drug as an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methadone HCl 10 milligram tablets for pain severe enough to require daily, around-the-clock, long-term opioid treatment. The Part D plan denied your request for a quantity limit exception 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 documentation indicates your doctor prescribed Methadone HCl to treat your chronic pain. The drug at issue was approved for a 30 day supply of 120 tablets. The documentation did not support an exception to the quantity limit criteria was met.Therefore, the plan is not required to cover Methadone HCl for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cellulose powder sustained release capsules prescribed daily for hypothyroidism. The Part D plan denied your request to cover the requested compounded medication. 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. This drug is a compounded drug. Therefore, we reviewed each ingredient individually.  The ingredients of the requested drug are: Cellulose, Methocel, and Liothyronine powder sodium.Cellulose and Methocel are non-prescription or over-the-counter (OTC) drugs. Medicare Part D does not cover non-prescription drugs. Therefore, the Cellulose and Methocel ingredients are not eligible for Part D coverage. Liothyronine powder sodium is a bulk Powder. Bulk powders (i.e., Active Pharmaceutical Ingredients for compounding) do not satisfy the definition of a Part D drug and are not covered by Part D. Therefore, none of the ingredients of the requested drug are Part D drugs. Compounded medications that do not contain at least one ingredient that meets the definition of a Part D drug are excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% Topical Patch prescribed apply one daily for compression fracture. The Part D plan denied your request because the diagnosis provided did not meet the requirements of Food and Drug Administration medically accepted indications. 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 records show your doctor prescribed Lidocaine 5% Topical Patch to treat your compression fracture. However, the Medicare approved compendium does not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% Topical Patch because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Tetrabenazine 12.5 milligram tablets to treat tardive dyskinesia.   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.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Valsartan 80 milligrams tablets (180 tablets per 90 days) to treat the enrollees condition.  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 Plan limits the amount of Valsartan 80 milligrams tablets to 31 tablets per 31 days.  The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm.  Therefore, an exception to the plans coverage criteria is not supported.  Our Physician Reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrocortisone acetate 25 milligram suppository prescribed for unknown diagnosis. The Part D plan denied your request because Medicare Part D does not cover less than effective Drug Efficacy Study Implementation 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 record shows the Hydrocortisone acetate is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover Hydrocortisone acetate. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methotrexate Sodium, 2.5 milligram tablets prescribed for mycosis fungoides. 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 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. According to Medicare rules, a drug prescribed for a Part D eligible individual cannot be considered a covered Part D drug if payment for the drug is available under Medicare Part A or B for that individual. Oral self-administered versions of covered cancer drugs may be paid by Medicare Part B if other coverage requirements are met. We determined that the Methotrexate Sodium is eligible for coverage under Medicare Part B. Therefore, the Part D plan is not required to cover the drug. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Meprobamate 400 milligram tablets prescribed as directed. The Part D plan denied your request for a tiering exception because the drug you requested 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.Meprobamate is a generic drug, which is not included on the plans formulary. The plan does not provide tiering exceptions for non-formulary drugs approved as formulary 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 Meprobamate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Norvasc 2.5 milligram tablets prescribed daily for hypertension. The Part D plan denied your request for a tiering exception. 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. The requested drug is being provided by your plan under a formulary exception. Norvasc 2.5 milligram tablets are 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 the plan is not required to cover Norvasc 2.5 milligram tablets because non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Epolamine 1.3% patch prescribed for spondylosis of the lumbar region. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Diclofenac Epolamine for spondylosis of the lumbar region. 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 a tiering exception request for Leflunomide 20 milligrams tablet to treat rheumatoid arthritis.   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.Leflunomide 20 milligrams tablet is a generic drug on Tier 3 of the plans formulary. There are no generic 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

You requested Tobramycin Nebulizer 300 milligrams/five milliliters prescribed for pseudomonas aeruginosa. The Part D plan denied the request because the requirements for prior authorization and quantity limits were not met. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee uses a nebulizer at home and has pseudomonas aeruginosa and bronchiectasis. This drug is eligible for coverage under Medicare Part B. Part B drugs are those that are used with durable medical equipment such as a nebulizer.We determined that the plan is not required to cover Tobramycin Nebulizer. The drug is eligible for coverage by your Part B plan; therefore, it is not eligible under your Part D plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested OxyContin 80 milligrams extended release tablet prescribed as directed for cancer related pain. The Part D plan denied your request for a tiering exception because the drug you requested 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. The record shows you were prescribed Oxycontin for your pain. Since the drug isnt on the plans formulary it is not eligible for a tiering 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 cover the Oxycontin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Actemra Injection 150 milligrams/ 0.9 milliliters prescribed once per month. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We requested additional information from the prescriber but no response was received.The plan requires a submission if a baseline latent tuberculosis screening test and supporting evidence that the enrollee had tried and failed to have an adequate response to or an intolerance to at least two preferred agents for the indication submitted. The documentation was insufficient and 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 Actemra Injection.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Dupixent 300 milligrams/2milliliters solution, pen-injector to treat the enrollees condition.   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.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lenvima 10 milligrams, two capsules to be given once a day for metastatic pancreatic adenocarcinoma to the liver. 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 records submitted at the reconsideration level.Lenvima is being requested to treat your condition. The Medicare approved compendia do not support the use of this drug for this condition. Hepatocellular carcinoma is not supported in the medical records.A physician reviewed your appeal and determined that the plan is not required to cover the Lenvima.