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

At issue is Vimpat 200 milligram tablets prescribed twice a day for epilepsy. The Part D plan denied the 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 being provided by the plan at the cost sharing level of the Specialty Tier. Specialty Tier drugs are not available for a tiering exception per Medicare rules.  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 Cyclobenzaprine HCl 10 milligram tablets prescribed twice daily for chronic back pain/spasms. 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 documentation indicates your doctor originally prescribed Cyclobenzaprine HCl for chronic back pain/spasms. Your doctor submitted a statement to indicate the diagnosis should be fibromyalgia. However, the medical records submitted indicate the drug at issue was prescribed for myalgia of unspecified site and radiculopathy sacral and sacrococcygeal region. The Medicare approved compendia do not support the use of the drug for your 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: Favorable

You requested Esbriet 267 milligram tablet prescribed for idiopathic pulmonary fibrosis. The Part D plan denied your request because other causes of your lung disease were not excluded. 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 states he prescribed Esbriet to treat your idiopathic pulmonary fibrosis. The Medicare approved compendium indicates the drug at issue is used to treat your diagnosis. The documentation also supports other causes of your lung disease have been excluded. In addition, a recent pulmonary function test is not required since this is a continuation of therapy.A physician reviewed your appeal and determined that the plan is required to cover Esbriet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Buprenorphine Hydrochloride 2 milligram sublingual tablets, 180 tablets for 30 days. The Part D plan denied the request because the medication was being prescribed for a non-medically accepted indication. Additionally, the amount of medication requested exceeded the quantity allowed by the plan for a 30-day supply. 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 submitted to the plan indicates that Buprenorphine Hydrochloride sublingual tablets are being prescribed for chronic pain syndrome with long-term opioid use. However, the Medicare approved compendia do not contain any citations to support the use of Buprenorphine Hydrochloride sublingual tablets for the treatment of the chronic pain syndrome with long-term opioid use.  The prescriber has noted at reconsideration that the enrollee is also taking Buprenorphine Hydrochloride for chronic opioid dependence. As outlined in the Medicare approved compendia, an acceptable indication for the use of Buprenorphine Hydrochloride sublingual tablets is for medically supervised withdrawal and maintenance treatment of opioid use disorder. However, no medical records have been submitted to validate the enrollee has opioid use disorder or to verify the enrollee is in a medically supervised withdrawal and maintenance treatment program. There is insufficient documentation to support that the enrollee is taking the medication for a medically accepted indication. Therefore, the medication is not eligible for coverage under Medicare Part D. Since the medication is not eligible for coverage, the amount prescribed will not be addressed.A physician reviewed your appeal and determined that the plan is not required to cover the Buprenorphine Hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% Patch prescribed for low back pain. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization requirements be met before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received 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 asked your prescriber to send us a supporting statement to show why the Lidocaine Patch is medically necessary. However, we did not receive the documentation.Your medical records show your doctor prescribed Lidocaine 5% Patch to treat your low back pain. 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 Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 20/10 milligram capsules prescribed to treat Alzheimers 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. 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 Amphetamine-Dextroamphetamine 20 milligram XR capsules prescribed for attention deficit hyperactivity disorder. 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. Your physician submitted a supporting statement. The records do not 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 Amphetamine-Dextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xanax one milligram tablet prescribed three times a day for anxiety. 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 records submitted at the reconsideration level. Your physician submitted a supporting statement. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Xanax.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto tablet to treat severe left ventricular systolic dysfunction, with a left ventricular ejection fraction below normal, and no physical findings suggestive of heart failure. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tofacitinib10 milligram tablets prescribed twice daily to treat pyoderma gangrenosum, psoriasis, hidradenitis, and psoriatic arthritis. 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 also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Tofacitinib.A physician reviewed your appeal and  determined that the plan is not required to cover the Tofacitinib.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Simbrinza 1%-2% suspension prescribed for the enrollees condition. 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.Simbrinza 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

You requested Myfortic 360 milligram tablet prescribed for prophylaxis of heart transplant rejection. 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 records show you prescribed Myfortic following the enrollees heart transplant for prophylaxis of organ rejection. 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 Myfortic 360 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lamictal 100 milligram tablets prescribed for the enrollees condition. 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.Lamictal is a non-formulary brand drug. 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 coverage for Buprenorphine Hydrochloride 2 milligram sublingual tablets. 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 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 submitted medical records indicate that Buprenorphine Hydrochloride sublingual tablets have been prescribed for severe pain due to radiation therapy due to the presence of liposarcoma and status post a thoracotomy after mass removal. However, the Medicare approved compendia do not contain any citations to support the use of Buprenorphine Hydrochloride sublingual tablets for the treatment of the noted conditions. A physician reviewed your appeal and determined that the plan is not required to cover the Buprenorphine Hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 10 milligram/actuation (2%) gel to treat male hypogonadism.   The Part D plan denied the request as prior authorization criteria were not met.  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 documentation does not satisfy the plans coverage criteria. Testosterone replacement therapy requires a diagnosis of primary or hypogonadotropic hypogonadism to satisfy Prior Authorization criteria. Approved compendia note that  The safety and efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism.   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 Ultomiris 11 milligram/11 milliliter solution prescribed for recurrent acute kidney injury and glomerulonephritis. 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 documentation indicates your doctor prescribed Ultomiris for recurrent acute kidney injury and glomerulonephritis. The Medicare approved compendia do not support the use of the biologic for your condition. As it cannot be determined that the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz XR 11 milligram tablets prescribed daily to treat seropositive rheumatoid arthritis. 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 also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated why all alternatives such as Rinvoq 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Xeljanz XR.A physician reviewed your appeal and  determined that the plan is not required to cover the Xeljanz XR.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azathioprine 50 milligram tablets prescribed as directed for chronic bronchiolitis with non-necrotizing granulomatous inflammation. 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 available. The record shows the physician prescribed Azathioprine for chronic bronchiolitis with non-necrotizing granulomatous inflammation, likely due to chronic hypersensitivity pneumonitis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azathioprine 50 milligram tablets prescribed as directed for Sjogrens 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 record shows the physician prescribed Azathioprine for Sjogrens syndrome. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeomin 100 unit vial injection. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the Xeomin injection has been received through buy and bill. However, this drug is eligible for coverage under Medicare Part B. Part B drugs are those that one cannot self-inject and are usually done within the physicians office or hospital outpatient setting.We determined that the plan is not required to cover Xeomin. The drug is eligible for coverage by your Part B plan; therefore, it is not eligible under your Part D plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hysingla ER 20 milligrams tablets to treat chronic pain syndrome and fibromyalgia. 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 indicated why all alternatives which are 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 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 a tiering exception request for Xarelto 20 milligram tablet. The Part D plan denied the 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.Xarelto is a brand drug on Tier 3 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. A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception for the Xarelto.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 1.5 milligram capsules prescribed for the enrollees condition. 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.Vraylar 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

At issue is Methocarbamol 500 milligrams tablets to treat muscle spasm. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.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 satisfied by the provided medical records. A physician reviewed your appeal and determined that the plan is not required to cover Methocarbamol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Levetiracetam ER 500 milligram tablets to treat the enrollees condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Levetiracetam ER is a generic drug on Tier 2 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temazepam 30 milligram capsules to treat insomnia. 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.We asked the 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.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 satisfied 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 Hydrocodone-acetaminophen 10-325 milligram tablets prescribed for unknown diagnosis. The Part D plan denied your request.We received a case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The record shows you purchased Hydrocodone-acetaminophen from a network pharmacy on March 1, 2021. 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 was not provided. Therefore, we determined that the plan is not required to reimburse you without the required documentation. Please submit proof of payment to your plan for reimbursement.