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

At issue is Benicar 20-12.5 milligram oral tablet prescribed for hypertension. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.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 medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Benicar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligram tablets prescribed twice daily for psoriatic arthritis. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. 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 medical records do not support why other drugs on the plans formulary would not work for you.A physician reviewed your appeal and determined that the plan is not required to cover Otezla nor offer a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Horizant ER 600 milligram tablets prescribed as directed for lumbar radiculopathy and chronic pain syndrome. 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 Horizant ER to treat your lumbar radiculopathy and chronic pain syndrome. 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 Horizant ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for the Zoster vaccine prescribed for shingles prevention. 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. A request was submitted to the prescriber to provide a diagnosis and to provide supporting medical records.  A reply from the prescriber was not received.  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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 5 milligram capsules prescribed for unspecified severe protein-calorie malnutrition. 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 Dronabinol 5 milligram capsules for nausea, anorexia, and failure to thrive. 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 Gamunex-C 10 gram/100 milliliter vial prescribed for other disorders of the nervous system. 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 medical records submitted show your doctor prescribed Gamunex-C for paraneoplastic syndrome. 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 Gamunex-C.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Rhopressa 0.02% ophthalmic solution to treat open angle glaucoma. The Part D plan denied the 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 Rhopressa to 2.5 milliliters per 25 days. The prescriber has indicated that the number of doses of the requested drug allowed by the plan has not been effective in treating the condition. The prescriber has ordered one drop in each eye at bedtime and requires 2.5 milliliters per 22 days. Therefore, an exception to the plans quantity limit coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligram tablet prescribed daily for insomnia. 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 medical records show your doctor prescribed Zolpidem Tartrate to treat your insomnia. 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 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 Zolpidem Tartrate. There was no evidence you have tried the non-high risk medication Doxepin. 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 Omnipod Cartridge 5 pack prescribed for insulin delivery. 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. 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 medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Omnipod Cartridge.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Retacrit 20,000 milliliter vial prescribed 4 vials per 28 days for chronic normocytic anemia. 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 Retacrit to treat your chronic normocytic anemia. 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 Retacrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20-milligram tablet to treat an unknown condition. The Part D plan denied your request because medical necessity was not established. As well, the requested drug has prior authorization criteria. We received an expedited 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.A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records. A reply from the prescriber was not received. 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Eucrisa 2% ointment prescribed for unspecified dermatitis. The Part D plan denied your 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 did not include a supporting statement to indicate formulary alternatives were tried and failed. A request for information was sent to the prescriber; however, no documentation was received. The documentation on file indicates the Eucrisa ointment at issue was prescribed for unspecified dermatitis, possibly allergic contact dermatitis. The Medicare approved compendia do not support the use of the drug at issue for this condition. As it cannot be determined that the drug was 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 Cymbalta 60 milligram capsule prescribed for excessive agitation. 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. At reconsideration level the documentation indicates that the enrollee has been on the name brand (requested drug) for years, treats excessive agitation with chronic testicular pain, and that the generic drug is not effective. We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need this medication. We did not receive the documentation requested. Specifically, no medical records are provided in this case for review. The documentation indicates your doctor prescribed Cymbalta to treat your excessive agitation and chronic testicular pain. However, the Medicare approved compendia do not support the use of this drug for your condition(s). Therefore, off formulary exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Cymbalta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spiriva HandiHaler 18 microgram capsules 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. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sirolimus 1 milligram tablet prescribed for a kidney transplant recipient. 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. The record shows the enrollee had a kidney transplant while covered under Medicare Part A. Drugs used to prevent transplant rejection may be covered under Part B when the transplant was paid for by Medicare. This drug is not eligible for coverage under Part D drug benefits. We determined that the plan is not required to cover Sirolimus.
Appeal type: Prescription Drug
Decision: Favorable

You requested Modafinil 100 milligram tablets prescribed for Parkinsons 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. Your physician indicates Modafinil is prescribed for excessive sleepiness due to obstructive sleep apnea and Parkinsons disease. The prescriber submitted medical records to support the diagnosis of sleep apnea. There is no indication that the enrollee will be taking armodafinil along with modafinil. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plans prior authorization requirements were met. A physician reviewed your appeal and determined that the plan is required to cover Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for PoDiaPN capsules.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.According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined this drug is not eligible for a tiering exception. We have also determined that the plan is not required to cover or reimburse you for PoDiaPN capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80 milligram per milliliter auto-injector. 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 included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.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 Namenda XR titration pack prescribed for Alzheimers dementia. 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. 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 prescribers statement does not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Namenda.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rybelsus 3 milligram tablets prescribed as directed. 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. Rybelsus 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 Enbrel Sureclick 50 milligram/milliliter pen injector prescribed as directed. 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 included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.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 Relistor 150 milligram tablets 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. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Methotrexate 2.5 milligram oral tablet. 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.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 received the documentation and included it in our review.Your medical records show your doctor prescribed Methotrexate to treat your rheumatoid arthritis. 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 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 Methotrexate. The medical records do not show the enrollee had an inadequate response or intolerance to first line therapy including non-steroidal anti-inflammatory drugs. 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 Sildenafil Citrate 100 milligram tablets to treat erectile dysfunction. The Part D plan denied the 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not FDA approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 20-10 milligram capsules prescribed as directed for late onset Alzheimer disease with behavioral disturbances, visual hallucinations, tearfulnes and fear. 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 Nuedexta to treat your late onset Alzheimer disease with behavioral disturbances, visual hallucinations, tearfulnes and fear. 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 Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benlysta 200 milligram/milligram auto injector prescribed as directed. 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 included on Tier 4 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Butalbital-Acetaminophen-Caffeine 50-325-40 milligram tablets prescribed to treat headaches. 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.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 medical records do not support why other drugs on the plans formulary would not work for you.A physician reviewed your appeal and determined that the plan is not required to cover Butalbital-Acetaminophen-Caffeine 50-325-40 milligram tablets.