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

At issue is Prolia 60 milligram/milliliter syringe prescribed for osteoporosis. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Prolia is a biological product on Tier 4 of the plans formulary. There are no biological products 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 Linzess 145 microgram capsules prescribed for chronic constipation. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Linzess is a brand name drug on Tier 4 of the plans formulary. There are no brand name drugs of the same type on the lower cost sharing tiers for your condition. 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 Potassium Chloride Extended Release 20 MEQ Tablets.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We requested additional documentation from your prescriber but did not receive a response. The documentation was insufficient to make a decision if the drug is covered under Part D Benefits. A physician reviewed your appeal and determined that the plan is not required to cover Potassium Chloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Glumetza 500 milligram oral tablet. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is not included on your plans formulary. 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 grant your request for a tiering exception. You may wish to submit a request to the plan to consider an off-formulary exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 5 milligram oral capsule prescribed twice daily for malignant neoplasm of pancreas unspecified. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The documentation shows your doctor prescribed Dronabinol to treat your loss of appetite related to malignant neoplasm of pancreas unspecified. However, the Medicare approved compendia do 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Eliquis 5 milligram tablets. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. Eliquis is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Eliquis at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine HCL 10 milligram tablets prescribed to take 1 tablet, by mouth, nightly, as needed to treat muscle spasms related to chronic back pain radiating to the right hip and groin. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows your doctor prescribed Cyclobenzaprine HCL 10 milligram tablets to treat muscle spasms related to chronic back pain radiating to the right hip and groin. However, the Medicare approved compendia do 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 Cyclobenzaprine HCL 10 milligram tablets.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Synthyroid 50 microgram tablets to treat the enrollees condition.We performed an independent and de novo review. We reviewed all documentation submitted.The record shows the plan has approved the non-formulary request for Synthyroid 50 microgram tablets. The requested drug has been approved coverage under Medicare Part D from February 16, 2021, through February 15, 2022.We determined that the plan is required to reimburse you for Synthyroid 50 microgram tablets. The plan has approved the non-formulary request. The Medicare rules above have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent ointment prescribed for unspecified osteoarthritis unspecified site and polyneuropathy unspecified. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows your doctor prescribed Lidocaine 5 percent ointment to treat your unspecified osteoarthritis unspecified site and polyneuropathy unspecified. However, the Medicare approved compendia do 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 percent ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Kineret 100 milligrams/0.67 milliliter injection prescribed for CPPD disease. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Kineret for CPPD disease. However, the Medicare approved compendia do 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 Kineret.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Santyl 250 units per gram ointment to treat a stage III pressure ulcer of the right trochanter area. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Santyl is a biological drug on Tier 4 of the plans formulary. There are no biological 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 coverage for Xolair 150 milligram per milliliter subcutaneous injection syringe prescribed for moderate persistent asthma. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not validated by the provided medical records. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Exjade 500 milligram tablets to treat iron overload secondary to multiple red cell transfusions. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. A physician reviewed your appeal and determined that the plan is not required to cover Exjade 500 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine-naloxone 8-2 milligram SL FILM  12 per 4 days AND 22 per 8 days prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows you filled prescriptions for Buprenorphine-naloxone at a network pharmacy. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that you paid for the drug was not provided. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Januvia 100 milligram tablet prescribed daily. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Januvia 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 Repatha SureClick Autoinjector 140 milligrams per milliliter prescribed every 14 days for hyperlipidemia. The Part D plan denied the request.We received the case to perform 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.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the records do not support why other drugs on the plans formulary would not work. The prescriber states the formulary alternative drug Praluent would be just as effective.A physician reviewed your appeal and determined that the plan is not required to cover Repatha SureClick.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hetlioz 20 milligram oral capsule. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The prior authorization request form shows your doctor prescribed Hetlioz to treat your non-24 hour sleep-wake disorder. However, there were no medical records submitted to support this condition. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Hetlioz 20 milligram capsules prescribed for the management of circadian rhythm sleep disorder free run type, non-24-hour sleep-wake disorder. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not validated by the provided medical records. 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 Arthrotec for the enrollees condition. We received an auto-forwarded reconsideration request from the coverage level.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We were unable to request medical records or other documentation to show why you need this medication. The documentation did not include your doctors name. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. 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 Arthrotec.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron Hydrochloride 4 milligram tablet to treat unspecified nausea and vomiting. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Ondansetron Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Taladafil 20 milligram tablets prescribed for erectile dysfunction. The Part D plan denied your request. We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows that Tadalafil was prescribed to you for use to treat sexual or erectile dysfunction. We determined that the plan is not required to cover the Tadalafil. Medicare excludes certain drugs from Part D coverage. Tadalafil is an excluded drug when used to treat sexual or erectile dysfunction; or to treat a condition other than sexual or erectile dysfunction for which the drug has not been approved by the Food and Drug Administration. The record does not indicate that the plan provides supplemental coverage for Tadalafil. Therefore, the plan is not required to cover it. 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

You requested Nulojix 250 milligram vial for anti-mitochondrial antibody associated inflammatory myositis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.The documentation shows your doctor prescribed Nulojix 250 milligram vial for anti-mitochondrial antibody associated inflammatory myositis. However, the Medicare approved compendia do 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 the Nulojix.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lubiprostone 8 microgram capsules prescribed for opioid-induced constipation. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Lubiprostone is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the noted condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm.  Medical records were requested and were not provided.  Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium Gel 1% prescribed three times daily for osteoarthritis of right knee. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not include medical records to 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 Diclofenac Sodium Gel 1%. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xopenex HFA 45 micrograms per actuation prescribed for unspecified bronchospasm and wheezing. The Part D plan denied the request. We received the case to perform 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 the doctor prescribed Xopenex HFA to treat the enrollees unspecified bronchospasm and wheezing. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed your appeal and determined that the plan is not required to cover Xopenex HFA.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Morphine Sulfate ER 60 milligram tablets prescribed 2 a day. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We requested information from your prescriber. We did not receive a response. The documentation is insufficient to determine if the drug is being used for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover Morphine Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ativan 1 milligram tablets prescribed for generalized anxiety disorder. The Part D plan denied the request because Ativan in not on the plans formulary and the documentation did not support a formulary exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber has noted at reconsideration that the enrollee is taking Lorazepam, which is the generic form of Ativan and is included in the formulary. However, the medication initially requested by the prescriber and reviewed by the plan is Ativan. Therefore, this review must address Ativan. Ativan is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives included in the plan to treat the noted condition 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 reviewer's opinion is that formulary exception criteria are not met. If the prescriber wants the plan to address the coverage for Lorazepam, a new request must be submitted to the plan.