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

At issue is Cytomel 25 microgram tablet prescribed to treat your condition. 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. The records submitted show that you have requested the brand name medication, as generics have caused weight gain and alopecia. However, your physician has indicated that you have not tried the generic alternative, Liothyronine, that the generic alternative would not be less effective, and that the generic alternative would not likely cause an allergy, adverse reaction, or harm to you. The records do not show why you cannot take other drugs on the plans formulary for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Cytomel 25 microgram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested step therapy coverage and a lower cost tiering exception for Trulicity, 1.5 milligrams per 0.5 milliliter injection pen. The Part D Plan denied your request because your physician did not provide a diagnosis to determine if the medication was being prescribed for a covered condition. We received an auto-forwarded reconsideration request from the coverage level. 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. Medical records were requested from your doctor during this review, but not received.The Part D plan is responsible for ensuring that covered Part D drugs are prescribed for medically accepted indications. The submitted documentation does not include any medical records from your physician stating the condition for which your medication is being prescribed. The prior authorization request form is incomplete as it does not include a diagnosis. Addtionally, there is no information regarding why a step therapy exception is medically required. Therefore, there is insufficient information to determine if the Trulicity is being prescribed for a medically accepted indication and meets requirements for a step therapy exception. A physician reviewed your appeal and determined that the plan is not required to cover the Trulicity.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Indomethacin Sodium 50 milligram tablets prescribed for gout. The Part D plan denied your request for a formulary exception. We received an expedited 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 you were prescribed Indomethacin Sodium to treat your gout. The Medicare approved compendia support the use of this drug for your condition. However, the plan formulary includes drugs that could be used to treat your condition. The prescriber statement indicates that nothing else works for you but does not indicate that all alternative drugs on the plan formulary have been tried or why you cannot take them. This decision does not address the medical necessity of the requested drug. It only means that it cannot grant a formulary exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Savella 50 milligram oral tablets prescribed daily to treat fibromyalgia nerve pain. The Part D Plan denied your request for a tiering 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. Savella 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

At issue is Zolpidem Tartrate ER 12.5 milligrams to treat insomnia. The Part D plan denied the request for a non-formulary exception. 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 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. 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

You requested Belladonna-Opium 16.2-60 milligrams prescribed for chronic interstitial cystitis/bladder pain syndrome. The Part D plan denied the appeal because the drug is excluded from coverage under the Medicare Part D 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. Your record shows that your doctor prescribed Belladonna Opium for chronic interstitial cystitis/bladder pain syndrome. The drug is not on your plans formulary. Belladonna-Opium is excluded from coverage under the Medicare Part D benefit. We have determined that your plan is not required to cover Belladonna-Opium because the drug is excluded from coverage under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is True Metrix glucose test strips prescribed for type 2 diabetes peripheral neuropathy. The Part D plan denied your request because items covered by Part B cannot be covered by Part D. 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. We determined that the plan is not required to cover the True Metrix glucose test strips because they are not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it may be covered under Part B. 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

You requested coverage for Methylphenidate Hydrochloride ER, 10 milligram tablets. The Part D plan denied the request stating that the medication was prescribed for a non-medically accepted indication. 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. The submitted prescriber statement indicates that the Methylphenidate Hydrochloride ER has been prescribed to treat the enrollees following conditions: idiopathic hypersomnia, sleep paralysis, cataplexy, and insomnia. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. 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 Methylphenidate Hydrochloride ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Glimepiride 4 milligram tablet prescribed twice daily to treat your condition. 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 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The records show your doctor prescribed Glimepiride to treat your condition. The plan requires prior authorization criteria 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 Glimepiride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 25 mg tablet prescribed daily for overactive bladder and mixed stress and urge incontinence. The Part D Plan denied your 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.Myrbetriq ER 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 of the plans formulary to treat the same condition. 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 Tresiba Flextouch insulin pen. The Part D plan denied the request for an off formulary exception. We received an auto-forwarded 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 a prescriber statement and medical records to show why the enrollee needs this medication. We did not receive the documentation requested.The documentation available for review does not include a prescriber statement or medical records. 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 Cosentyx 150 milligram subcutaneous injection prescribed as directed for psoriasis. The Part D Plan denied your request for a tiering 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. Cosentyx is a biologic drug on Tier 1 of the plans formulary. Tier 1 drugs are not eligible for a tiering exception because they are already classified as the lowest tier on the plans formulary. 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 Cosentyx 300 milligram pen prescribed for the enrollees plaque psoriasis. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription biologics. If prior approval is not obtained, the plan may not cover the biologic. 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 documentation supports the biologic was prescribed for the enrollees diagnosis of plaque psoriasis. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate HCL 20 milligrams prescribed as directed for severe fatigue. The Part D plan denied your request because the provided diagnosis 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 Methylphenidate HCL 20 milligrams to treat your severe fatigue. The use of the requested drug to treat the provided diagnosis is an off-label use. 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 Methylphenidate HCL 20 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Intrarosa 6.5 milligrams to treat postmenopausal vaginal atrophy. The Part D plan denied your request for a non-formulary exception. 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 records submitted at the reconsideration level. The physician submitted a supporting statement. The prescriber statement indicates that the enrollee has tried and experienced therapeutic failure(s) with all alternatives. However, medical records have not been submitted for review. Therefore, the documentation available 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 Intrarosa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 50 milligram capsule prescribed daily for attention-deficit/hyperactivity disorder. We received an auto-forwarded reconsideration request from the coverage level. 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 to show why you need the medication. Specifically, we asked for records to show why other drugs on the plan's formulary would not work for you. However, we did not receive the documentation.A physician reviewed your appeal and determined that the plan is not required to cover Vyvanse.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Benztropine Mesylate 1 milligram tablets prescribed twice daily for anxiety, paranoia, hallucinations, insomnia, suicidal ideations, and 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. The submitted documentation indicates your doctor prescribed Benztropine Mesylate for anxiety, paranoia, hallucinations, insomnia, suicidal ideations, and dementia. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not 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

At issue is Avycaz 2.5 gram vial prescribed for extended-spectrum beta-lactamase wound infection. 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. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. 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 Avycaz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20-milligram tablets to treat pulmonary  hypertension associated with sarcoidosis. The Part D plan denied the request because the diagnoses are not medically accepted indications. The approved use for this drug is pulmonary arterial hypertension World Health Organization Group 1. 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 medical records show that your doctor prescribed Sildenafil Citrate for your pulmonary hypertension with associated with sarcoidosis. The use of the requested drug to treat the provided diagnosis of pulmonary hypertension associated with sarcoidosis, World Health Organization Group 5, is not a medically accepted indications for the use of this drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D.The physician reviewers opinion is that the plan is not required to cover Sildenafil because the diagnoses are not medically accepted indications per Medicare law.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Climara 0.1 milligram transdermal patches prescribed as directed. The Part D plan denied your request for a tiering exception because there were no brand drugs of the same type on the lower cost sharing tiers. 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. Climara 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: Favorable

You requested Repatha Sureclick 140 milligram auto-injector prescribed once every two weeks as prophylaxis for heart attack, stroke, and coronary revascularization in an enrollee with cardiovascular disease. The Part D plan denied your request because the quantity limits were exceeded. 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 medical records show you prescribed Repatha Sureclick 140 milligrams. The prescriber statement indicates you wish to fill two prefilled auto-injectors for a 28 day supply. The quantity limit has not been exceeded. Therefore, the plan is required to cover the requested quantity of two Repatha Sureclick 140 milligram auto-injectors per 28 days.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Loratadine 10 milligram tablet prescribed for allergies. The Part D plan denied the appeal because the drug is excluded from coverage under the Medicare Part D drug plan. The requested drug is available without a prescription and available over-the-counter. 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. Loratadine is excluded from coverage under the Medicare Part D benefit because the drug does not meet the definition of a Part D drug. This is not to say that this drug does not benefit you, just that Medicare does not allow payment for this drug under the Medicare Part D benefit.We have determined that your plan is not required to cover Loratadine because the drug does not meet the definition of a Part D drug under Medicare law.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pradaxa 75 milligram capsule to be given twice a day for atherosclerotic heart disease of native coronary artery without angina pectoris and paroxysmal atrial fibrillation. The Part D plan denied the drug because it was not medically necessary. The plan requires prior approval before covering some 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 records submitted at the reconsideration level.Pradaxa is being requested to treat your conditions. The Medicare approved compendia do not support the use of this drug for your conditions.A physician reviewed your appeal and determined that the plan is not required to cover the Pradaxa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xopenex HFA 45 microgram aerosol prescribed for chronic obstructive pulmonary disease. 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. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. 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 Xopenex HFA.