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

You requested Farxiga, 5-milligram tablet prescribed once daily for heart failure and diabetes. The Part D plan denied your request because the information provided was not sufficient to support approval for medical necessity. Specifically, the medical reasons you were not able to use the listed drugs for your condition. 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 Farxiga to treat your heart failure and diabetes. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, would likely cause harm or not be as effective for the enrollee as the requested 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 Rytary 195 milligram capsules prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Rytary is a brand drug on Tier 4 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

You requested Welchol 625 milligram tablets prescribed three times daily for diarrhea secondary to postcholecystectomy syndrome. The Part D plan denied your request because it did not indicate if Glipizide ER and Metformin were tried and failed. 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. It is indicated by the prescriber that Welchol has not been prescribed for diabetes. The records show Welchol was prescribed to treat diarrhea secondary to postcholecystectomy syndrome. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Welchol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ztlido 1.8% patch prescribed three time daily for chronic back and knee pain. The Part D plan denied your off formulary request because the documentation did not support medical necessity. 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.Ztlido 1.8% patch was ordered to treat the enrollees chronic back and knee pain. However, the Medicare approved compendia do not support the use of the requested drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Ztlido 1.8% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuplazid 34 milligram capsules prescribed daily for major neurocognitive disorder, mixed lewy body, and subcortical vascular dementia. 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 major neurocognitive disorder, mixed lewy body, and subcortical vascular dementia. However, the Medicare approved compendia do not support the use of this drug for your condition. You have indicated the diagnosis of Parkinsons was made after the onset of psychotic symptoms.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 Horizant ER 600 milligrams prescribed daily for peripheral neuropathy. The Part D plan denied your request because the Food and Drug Administration has not approved this drug for your diagnosis. 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 Horizant ER to treat your peripheral neuropathy. However, 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 Horizant ER. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 250 milligrams prescribed daily for hypersomnia secondary to central sleep apnea syndrome. The Part D plan denied your request because the Food and Drug Administration has not approved this drug for your diagnosis. 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 Armodafinil to treat your hypersomnia. However, 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 Armodafinil. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligrams prescribed daily for non-24 hour sleep-wake cycle disorder. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an auto-forwarded 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Hetlioz 20 milligrams daily for non-24 hour sleep-wake cycle disorder. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records 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 the Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Adefovir Dipivoxil 10 milligram tablets prescribed daily for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for a lower cost-sharing tier. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Adefovir Dipivoxil is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier 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 Lidocaine 5 percent patch prescribed as needed for superficial peroneal nerve dysesthesia and neuritis status post right tibiotalar replacement and tendo-Achilles lengthening. 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Lidocaine 5 percent patch as needed to treat your superficial peroneal nerve dysesthesia and neuritis. 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 Lidocaine 5 percent patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulance 3 milligram tablet prescribed for irritable bowel syndrome. The Part D plan denied your request for a tiering exception because Trulance is a Tier 3 medication with no alternate drugs on a lower tier. We received an expedited auto-forwarded reconsideration request from the plan. 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 documentation shows Trulance is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type for treating the enrollees condition 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 cover Trulance.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dysport 1000 units prescribed for severe spasticity. The Part D plan denied the request because the biologic was not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows Dysport is prescribed to treat the enrollees spasticity. However, this drug is eligible for coverage under Medicare Part B. This biologic is to be administered in the office by a healthcare professional.We determined that the plan is not required to cover Dysport.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Januvia 100 milligrams prescribed daily for diabetes mellitus. The Part D plan denied your request for a tiering exception. We received a 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. Januvia 100 milligrams 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 cover Januvia 100 milligrams because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5 milligrams prescribed as directed to treat benign prostatic hyperplasia. The Part D plan denied your request because the drug you requested is not included on your plans formulary. 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 that your doctor prescribed Tadalafil 5 milligrams to treat your benign prostatic hyperplasia. The Medicare approved compendium supports the use of this drug to treat your condition. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligrams/milliliter prescribed every two weeks for hyperlipidemia. 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.You submitted a supporting statement and medical records. Your supporting statement indicates that the enrollee has tried Pravastatin, which yielded constant side effects. Your statement also indicates that the enrollee has an allergy to all statin drugs. The medical records include laboratory results, which confirm a diagnosis of hyperlipidemia. However, the medical records submitted do not support your statement that the enrollee is allergic to statin drugs. The records do not adequately show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 5 milligram capsules prescribed as directed for nausea. 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 documentation shows the doctor prescribed Dronabinol to treat constant nausea that developed after a stroke in 2019. However, the Medicare approved compendia do not support the use of Dronabinol for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Emsam, 6-milligram 24 hour patch to treat major depressive disorder.   The Part D Plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The enrollee does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plans coverage criteria and has not indicated why all alternatives required by the Plan would likely cause harm or not be as effective for the enrollee as the requested 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 Farxiga, 10 milligram tablets prescribed for type 2 diabetes. The Part D Plan denied your request for a tiering exception because  the submitted documentation did not explain why the plans alternative drugs in lower tiers would not work just as well. 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 Farxiga is not eligible for a tiering exception.Farxiga is a brand name drug on Tier 4 of the plans formulary. The submitted documentation does not address why the brand name drugs on the lower tiers of the plans formulary have been tried and failed, or are contraindicated. Therefore, the plan cannot grant a tiering exception for the Farxiga at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 250 milligrams prescribed daily for multiple sclerosis related fatigue. The Part D plan denied your request because the medication is 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 records show you prescribed Armodafinil to treat the enrollees fatigue. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Adderall 30 milligrams prescribed as directed for major depressive disorder and anxiety. The Part D plan denied the 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 record shows you were prescribed Adderall 30 milligrams as directed for major depressive disorder and anxiety. 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 Adderall because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate HCl 10 milligram tablets prescribed twice daily for Major Depressive Disorder. 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 to treat Major Depressive Disorder. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tobramycin 28 milligram inhalation capsules prescribed four capsules twice daily for bronchiectasis with Pseudomonas aeruginosa. 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 to treat bronchiectasis with Pseudomonas aeruginosa. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alprazolam 1 milligram tablets prescribed daily for anxiety and panic disorder. The Part D plan denied coverage because insufficient documentation was provided. 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 prescriber statement shows the physician prescribed Alprazolam for anxiety and panic disorder. The Medicare approved compendia do support the use of this drug for those conditions.The prescriber statement also shows the enrollee has been assessed for risk versus benefit in using this High Risk Medication. However, the plan requires an intolerance or contraindication to other drugs for the enrollees condition 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 Alprazolam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium Gel 1% prescribed daily for arthritis of carpometacarpal joint of both thumbs. 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 including the case file from the plan, and any records submitted at the reconsideration level.Your medical records show your doctor prescribed Diclofenac Sodium gel to treat your arthritis of carpometacarpal joint of both thumbs. The plan requires an intolerance or contraindication to nonsteroidal anti-inflammatory drugs before they will cover the requested drug. The prescriber answered 'No' when asked if the treatment of the drug was necessary due to concern of an intolerance or a contraindication to two oral nonsteroidal anti-inflammatory drugs. The plan's coverage criteria are not met based on the documentations submitted.A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium gel.