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

At issue is Pentazocine/Naloxone 50 mcg/.05mg tablets prescribed twice daily. 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. We also researched Medicare systems and reviewed the enrollment data available.Your physician submitted a prescribers statement. The records show that the physician prescribed Pentazocine/Naloxone. The physician stated that this drug gave the most relief. The plan formulary includes other drugs that could be used to treat your condition. However, the records do not show all alternative drugs on the plan formulary have been tried and for your condition. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit. A physician reviewed your appeal and determined that the plan is not required to cover an off-formulary exception for Pentazocine/Naloxone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuplazid 34 mg capsule prescribed as directed for the treatment of Lewy Body Dementia. The Part D plan denied your request because it 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.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 the enrollees 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 Nuplazid 34 mg capsule because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benzonatate 100 milligram capsule prescribed for cough.   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.Drugs prescribed for the symptomatic treatment of cough and colds are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligrams prescribed for the enrollees irritable bowel syndrome. 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 a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria, as the prescriber has indicated the enrollee has already received an initial 14-day course and two additional 14-day courses of the drug.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 Almotriptan Malate 12.5 milligrams prescribed as needed for chronic migraines. 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 plan. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.A supporting statement and medical records were submitted. The medical records show Almotriptan Malate was ordered to treat the enrollees condition. The Medicare approved compendium supports the use of the requested drug for this condition.However, the records do not show why the enrollee cannot take other drugs on the plans formulary for this condition. Specifically, Rizatriptan and Eletriptan have not been tried.A physician reviewed your appeal and determined that the plan is not required to cover Almotriptan Malate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ethyl Chloride 100% topical spray for your condition. The Part D plan denied your request because the drug at issue did not meet the definition of a Part D 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.We determined that the plan is not required to cover Ethyl Chloride because it is excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchase drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Daliresp 500 micrograms prescribed daily for chronic obstructive pulmonary disease. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Daliresp is a brand drug on Tier 4 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.The physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Uloric 80 milligram tablets prescribed as directed for gout. You requested that the plan provide coverage for a non-formulary drug. The plan did not make a decision within the required timeframe. 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 prescriber statement shows the physician had prescribed Uloric to treat gout. The Medicare approved compendium does support the use of Uloric for this condition.However, the records do not show why the enrollee cannot take other drugs on the plans formulary for gout. Specifically, the prescriber statement only shows that the enrollee failed treatment with Allopurinol. The documentation does not show why other available drugs on the formulary were not tried or considered.A physician reviewed your appeal and determined that the plan is not required to cover Uloric.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol 2.5milligrams/ 3 milliliter nebulizer solution prescribed as directed for 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 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 Albuterol 2.5milligrams/ 3 milliliter nebulizer solution to treat your asthma. The Medicare approved compendia do support the use of this drug for your condition. However, we determined that the drug is not eligible for Part D coverage. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. 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 Albuterol 2.5milligrams/ 3 milliliter nebulizer solution because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit.You may wish to submit a request for Albuterol 2.5milligrams/ 3 milliliter nebulizer solution to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine HCl 2 milligrams sublingual tablets prescribed for chronic pain syndrome. 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. Your medical records show your doctor prescribed the requested drug to treat chronic pain syndrome. The Medicare approved compendia supports the use of this drug for your condition. Your Plan requires documentation of opioid dependence. However, this condition is not found in the medical records. Therefore, the requested drug 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 Lynparza 150 milligrams prescribed twice daily for the enrollees malignant neoplasm of pancreas. The Part D plan denied coverage 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 records submitted at the reconsideration level. The enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has indicated the enrollees disease progressed on at least 16 weeks of a first line platinum based chemotherapy regimen.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nexium 40 milligrams prescribed as directed for Barretts esophagus. The Part D plan denied the 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. The record shows you were prescribed Nexium for Barretts esophagus. 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 the Nexium because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Spiriva HandiHaler 18 microgram inhalant prescribed for chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception because Spiriva HandiHaler is a brand name Tier 2 drug and the lower cost-sharing tiers only contain generic alternative drugs. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The record shows Spiriva HandiHaler is being prescribed for chronic obstructive pulmonary disease. The Medicare approved compendia supports the use of the requested drug for your condition. The plan shows Spiriva HandiHaler is a brand name Tier 2 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine 5 milligram patch prescribed weekly for pain secondary to lumbar spondylolisthesis. 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 records show the physician has prescribed Buprenorphine patch to treat your chronic pain, which is a medically accepted indication. Your physician has also indicated that you have tried Oxycodone and Dilaudid. However, the records do not show why you cannot take other drugs on your plans formulary for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stelara (solution in prefilled syringe) 90 milligrams/milliliter prescribed subcutaneously every eight weeks  for  Crohns Disease. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. 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. Stelara is a brand drug on Tier 5, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the specialty tier from the tiering exception process. 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 Stelara. A tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Acitretin, 25 milligram capsules for the treatment of pityriasis rubra pilaris. The Part D plan denied your request because pityriasis rubra pilaris is not a Food and Drug Administration-approved diagnosis for the use of this 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.  A physician reviewed your appeal and determined that the plan is not required to cover the Acitretin because pityriasis rubra pilaris is not a medically accepted indication to use this drug.The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, the requested drug does not meet the definition of a Medicare Part D drug and is therefore not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cosopt PF, 2/0.5% solution eye drops prescribed for glaucoma. The Part D Plan denied your request for a lower-cost tiering exception because the medication is not included on the plans formulary. We received 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. A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.Cosopt PF is not included on your plans formulary. While the plan has approved the request for coverage of the non-formulary medication, a lower-cost tiering exception cannot be approved. The plan does not grant tiering exceptions to non-formulary drugs. Therefore, this drug is not eligible for coverage at a lower-cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Praluent 150 milligram pen injection prescribed daily for dyslipidemia. The Part D plan denied your request because the prior authorization criteria and utilization management criteria for the drug was not met. We received an expedited 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. 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 amount of the medication including prior authorization criteria questions. We received the documentation and included it in our review.Your medical records show your doctor prescribed Praluent to treat your dyslipidemia with high low density lipoprotein and low high density lipoprotein. Your physician sent answers to the prior authorization questions that indicate you have a diagnosis of hyperlipidemia and heterozygous familial hypercholesterolemia with associated angina and prior cardiac ablation. Your low density lipoprotein cholesterol was 78 despite taking Lipitor 80 milligrams daily. Crestor and fish oil were tried and were ineffective. However, the record does not include information to support the reason your physician prescribed the drug above the quantity limit. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover the requested quantity of Praluent 150 milligram pens 2 pens per 30 days.A physician reviewed your appeal and determined that the plan is not required to cover the Praluent, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Revlimid 20 milligrams prescribed daily for follicular lymphoma. Upon review, the Part D plan denied coverage because the plan covers drugs filled at an out-of-network pharmacy only in certain limited circumstances. We received an expedited auto-forwarded request from the coverage letter to reconsider the appeal. We performed an independent and de novo review. We reviewed all documentation submitted. The record shows the enrollee received the Revlimid due to follicular lymphoma. This drug is on the plans formulary and the Medicare compendium supports orphan drug designation for the enrollees condition. We determined that the plan is required to cover the Revlimid. The Medicare rules above have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Uloric 80 milligram tablets prescribed as directed for gout. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The physician submitted a supporting statement. The documentation shows the physician had prescribed Uloric to treat gout. The Medicare approved compendium does support the use of Uloric for this condition.However, the records do not show why the enrollee cannot take other drugs on the plans formulary for this condition. Specifically, the prescriber statement shows the enrollee could not tolerate Allopurinol, Zyloprim, and Colchicine, due to severe nausea and diarrhea. The documentation does not show why other available drugs on the formulary were not tried or considered. A physician reviewed your appeal and determined that the plan is not required to cover Uloric.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate mofetil 1000 milligrams prescribed twice daily for a bilateral lung transplant. 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 Mycophenolate mofetil 1000 milligrams twice daily to treat your bilateral lung transplant. 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 Mycophenolate mofetil 1000 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Durezol 0.05% ophthalmic emulsion prescribed for unspecified keratoconjunctivitis of right eye and limbal stem cell 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. Your medical records show your doctor prescribed the requested drug for unspecified keratoconjunctivitis of right eye and limbal stem cell 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 the requested drug.