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

You requested Cyclobenzaprine HCL 5 milligram tablets prescribed twice daily for neck pain and spondylosis of the cervical region. 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. Your medical records show your doctor prescribed Cyclobenzaprine HCL to treat your neck pain and spondylosis of the cervical region. 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 Cyclobenzaprine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nitrofurantoin MCR 50 milligram capsules prescribed to treat the diagnoses of painful urination (dysuria) and urinary tract infection. The Part D plan did not provide a timely redetermination decision for the formulary exception request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Nitrofurantoin MCR 50 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Rytary 23.75 milligram-95 milligram capsules prescribed for Parkinsons disease. The Part D plan denied your request for a tiering exception because Rytary is a brand name Tier 4 drug and there are no generic drugs of the same type on the lower cost sharing levels. 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 plan shows Rytary is a brand name Tier 4 drug. There are no generic 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 a tiering exception for Symbicort 160 micrograms/4.5 micrograms actuation inhalation aerosol prescribed to treat the enrollees condition. The Part D plan did not provide a timely redetermination decision.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.Symbicort 160 micrograms/4.5 micrograms inhaler is a brand drug on Tier 3 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat the enrollees condition have been tried or deemed contraindicated. 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 the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fentanyl 25 microgram/hour transdermal patch for chronic pain. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The prescriber statement and medical records show your doctor prescribed Fentanyl to treat your chronic back pain. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Fentanyl. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Rivastigmine 13.3 milligram per 24-hour topical patch prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the documentation did not show that all generic drugs on lower tiers had been tried or considered for the treatment of the enrollees 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.The plan shows Rivastigmine is a generic Tier 4 drug on the plans formulary. The prescriber did not address why all alternate medications, on lower tiers, would not work for the enrollee. All drugs on lower tiers have not been tried. Therefore, this drug is not eligible for a tiering exception. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vios aerosol deliver system. 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 also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the Vios aerosol deliver system may be eligible for coverage under Part B or Durable Medical Equipment Benefit under Medicare rules.  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 coverage for Xeljanz 5 milligram tablets prescribed daily for immunodeficiency/immune dysregulation disorder caused by a Gain-of-Function (GOF) mutation In the STAT3 transcription factor. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 you were prescribed Xeljanz for immunodeficiency/immune dysregulation disorder caused by a Gain-of-Function (GOF) mutation In the STAT3 transcription factor. In review of the Medicare approved compendia, immunodeficiency/immune dysregulation disorder caused by a Gain-of-Function (GOF) mutation In the STAT3 transcription factor is not a medically accepted indication for Xeljanz. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Xeljanz at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 2.5 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.Eliquis 2.5 milligram tablets 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. Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 30 milligrams per 1.5-milliliter pump to treat erectile dysfunction and testicular hypofunction. 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.Drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent patches prescribed as directed for chronic low back pain with right-sided sciatica. 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 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 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 Lidocaine 5 percent patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Colestipol 1 gram 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.Colestipol is a brand drug on Tier 3 of the plans formulary. However, the prescribed diagnosis is a non-medically accepted indication. 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

At issue is Modafinil 200 milligram tablets prescribed daily for other fatigue due to multiple sclerosis.   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.DrugDex, a Medicare approved compendia states:  In a 9-week, phase 2, single-blind, 2-center pilot study (n=72), 2 weeks of modafinil 200 mg daily significantly improved Fatigue Severity Scale (FSS) scores compared with placebo in patients with relapsing-remitting or progressive multiple sclerosis.  Therefore the requested drug is being used for a medically accepted indication. However, the documentation does not satisfy the plans coverage criteria.  The prescriber has indicated that the diagnosis is fatigue due to multiple sclerosis.  Therefore, an exception to the plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Januvia 100 milligram tablets. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Januvia is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolipidem Tartrate 5 milligram tablets to treat insomnia from lumbar, thoracic and radicular pain. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Zolipidem Tartrate. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dexilant 60 milligram capsules prescribed two capsules each day to treat your gastroesophageal reflux 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan limits the amount of Dexilant provided to 30 capsules per 30 days. The prescriber has not provided patient specific clinical rationale indicating that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported.  Our physician reviewer's opinion is that an exception to the quantity limit criteria is not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lotrel 5-10 milligram capsule prescribed daily for essential hypertension. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Lotrel 5-10 milligram capsule.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Imatinib Mesylate 400 milligram oral tablet for chronic myeloid leukemia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Imatinib to treat your chronic myeloid leukemia. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided shows the enrollee has satisfied the plan's coverage criteria. The medical records show you previously tried Dasatinib, a tyrosine kinase inhibitor, with incomplete response. A physician reviewed your appeal and determined that the plan is required to cover Imatinib. The physician reviewer also determined that an exception to the plans prior authorization requirements can be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ezetimibe 10 milligram tablets prescribed for paroxysmal atrial fibrillation. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us medical records and a statement as to why the drugs on the lower tiers were ineffective or had an adverse effect. We did not receive a response. Ezetimibe is generic drug on Tier 3 of the plans formulary. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you. 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 coverage for Tadalafil 5 milligram tablets prescribed for benign prostatic hyperplasia with lower urinary tract symptoms. The Part D plan denied the request for coverage.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.Tadalafil is not one of the medications listed in the plans formulary to treat benign prostatic hyperplasia. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives included in the plan would likely not be as effective as the requested drug for this condition, 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 Austedo 6 milligram oral tablet prescribed twice daily for positive dystonia. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records show your doctor prescribed Austedo to treat your positive dystonia. 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.A physician reviewed your appeal and determined that the plan is not required to cover Austedo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nubeqa 300 milligram tablets prescribed to treat metastatic prostate cancer. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Your medical records show your doctor prescribed Nubeqa to treat your metastatic prostate cancer. 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 Nubeqa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch to treat sciatica from lumbar spinal stenosis and radiculopathy. 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.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.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 Vemlidy 25 milligram tablets prescribed daily for chronic hepatitis B infection. The Part D plan denied coverage.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 doctor submitted a supporting statement. The statement does not indicate that you satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Repatha Sureclick Auto-injector prescribed to treat hyperlipidemia with atherosclerotic cardiovascular 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 records submitted at the reconsideration level. Your medical records show your doctor prescribed Repatha Sureclick Auto-injector to treat your hyperlipidemia. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plan requires documented low-density lipoprotein cholesterol reduction while on therapy. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Repatha Sureclick Auto-injector.