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

You requested a tier exception for Myrbetriq 50 milligram tablets prescribed for overactive bladder. The Part D plan denied your request for a tiering exception because Myrbetriq is a brand name Tier 4 drug and the lower cost-sharing tiers only contain generic alternative drugs. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Myrbetriq is a brand name Tier 4 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eliquis 5 milligram tablets prescribed twice daily. The Part D plan denied your 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. Eliquis 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. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexium 40 milligram oral capsule prescribed daily for gastroesophageal reflux disease without esophagitis. 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.Nexium is a brand drug that is not on the plans formulary. Per Medicare guidelines a tiering exception cannot be allowed for a drug that is not 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 the tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clobetasol Propionate 0.05% cream prescribed for chronic obstructive pulmonary disease exacerbation. 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. The submitted documentation indicates your doctor prescribed Clobetasol Propionate cream for chronic obstructive pulmonary disease exacerbation. The Medicare approved compendia do not support the use of this 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: Unfavorable

At issue is a tiering exception request for Potassium Citrate 15 milliequivalent ER tablets prescribed daily 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.Potassium Citrate is a generic drug on Tier 3 of the plans formulary. Your doctor submitted a supporting statement. The statement did not address why all alternative lower-tier medication on the plans formulary would not work for you. All generic drugs on lower tiers have not been tried. 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 Hetlioz 20 milligram tablet to treat non-24 hour sleep-wake disorder. 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 any information submitted at the reconsideration level.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The documentation previously provided addressed the plans coverage criteria and those criteria were not satisfied. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin Enteric Coated 81-milligram tablet. The case was auto-forwarded by the plan.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available over-the-counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus 1 milligram capsules prescribed following a kidney transplant. The plan did not make a decision within the required timeframe. The case was auto-forwarded by the plan. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your records show your doctor prescribed Tacrolimus to prevent rejection following a kidney transplant. Based on the information provided, the drug is eligible for Part B coverage. Therefore, the drug is not eligible for Part D coverage in this case.
Appeal type: Prescription Drug
Decision: Favorable

At issue is reimbursement for the Shingrix vial kit. 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 records show you have a receipt for the Shingrix vaccine and are requesting reimbursement. Your date of birth shows you are over 50 years of age. The vaccine is indicated for the prevention of shingles in individuals 50 years or older. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Amitriptyline HCl 10 milligram tablets prescribed for dyspepsia and gastroesophageal reflux disease. 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. The submitted documentation indicates your doctor prescribed Amitriptyline HCl for dyspepsia and gastroesophageal reflux disease. At reconsideration, your doctor submitted a statement to indicate you have a diagnosis of depression; however, the medical records submitted support the diagnosis of functional dyspepsia. The Medicare approved compendia do support the off-label use of this drug for your condition. As it is determined that the drug was prescribed for a medically accepted indication, coverage can be allowed.A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Flector 1.3 percent topical patch prescribed daily for chronic pain. 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 Flector for chronic pain. In review of the Medicare approved compendium, chronic pain is not a medically accepted indication for Flector. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Flector at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nubeqa 300 milligram tablets prescribed as 120 tablets per 30 days for prostate cancer, non-metastatic castration resistant. The Part D plan denied the 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 plan requires prior authorization criteria be met for this drug to be covered. The documentation provided addressed the plans coverage criteria, which are approved by Medicare, and those prior authorization criteria were not satisfied. The prior authorization requirements have not been met. A physician reviewed your appeal and determined that the plan is not required to cover Nubeqa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Myrbetriq ER 25 milligram tablets prescribed daily for urinary urge incontinence. 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. Myrbetriq ER 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. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 1% gel. 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. The submitted documentation does not include medical records to support a covered diagnosis. A request for a supporting statement and medical records was sent to your doctor. No further documentation was received. 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: Unfavorable

At issue is a tiering exception request for Nystatin Powder 100,000 units/gram to treat the enrollees condition. 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.Nystatin Powder is a generic drug on Tier 3 of the plans formulary. There are no generic 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 a tiering exception request for Xiidra 5 percent ophthalmologic solution for the enrollees conditon. 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.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Omega-3-acid ethyl esters 1-gram capsules prescribed as directed for hyperlipidemia. The Part D plan denied your request because the drug was not Food and Drug Administration approved 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. The medical records show the doctor prescribed Omega-3-acid ethyl esters for hyperlipidemia. 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 Omega-3-acid ethyl esters.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Eliquis 2.5 milligram tablets prescribed in reference to atrial fibrillation. The Part D plan denied your request for a tiering exception because Eliquis is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Eliquis is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels for your condition. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuedexta 20/10 milligram capsules prescribed daily for pseudobulbar affect.The Part D plan denied your request for a tier change request because Tetrabenazine is in the specialty tier of your list of covered drugs. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Nuedexta is a brand name Tier 5 drug. Your plan does not allow you to receive drugs in this tier at a lower cost share.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligrams/milliliter to treat hyperlipidemia. 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 documentation provided addressed the plans coverage criteria, and those criteria were not satisfied. 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 Humalog Kwikpen 100 units/milliliter prescribed every six hours for type 2 diabetes mellitus. 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 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 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 Humalog Kwikpen 100 units/milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Dupixent 300 milligram per 2 milliliter subcutaneous injection pen prescribed for severe persistent asthma. 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 documentation does not satisfy the plans coverage criteria. The prescriber has addressed the authorization criteria; however, the responses do not satisfy the plans requirements for coverage of this medication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Movantik 12.5 milligram oral tablet to treat opioid-induced constipation in an enrollee with chronic noncancer pain.   The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we read 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 request was submitted to the prescriber to address the plans off-formulary criteria and to provide supporting medical records.  A reply from the prescriber was not received.  The prescriber has not provided patient specific clinical rationale, supported by medical records, as to 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 formulary 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 Jardiance 10 milligram oral tablet prescribed for type II diabetes. 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.Jardiance is a brand name drug on Tier 3 of the plans formulary. There are no brand name drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception. There are no lower tiered brand drugs of the same type to treat your condition.A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine hydrochloride 2 milligram sublingual tablets prescribed as directed for an enrollee with chronic pain syndrome and chronic prescription opiate use. 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 Buprenorphine hydrochloride for an enrollee with chronic pain syndrome and chronic prescription opiate use. The Medicare approved compendia do not support the use of this drug in sublingual form for these conditions. At reconsideration, a diagnosis of opiate abuse disorder was also given. The medical records provided by the prescriber do not support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Buprenorphine hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Otezla 30 milligram tablets prescribed twice daily for lichen planus. 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. We also researched Medicare systems and reviewed the enrollment data available. At initial determination and redetermination the diagnosis of lichen planus was given. At reconsideration a diagnosis of moderate to severe plaque psoriasis was given. No medical records were provided by the prescriber to support this diagnosis change. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vascepa 1 gram softgel capsules prescribed for hypertriglyceridemia and prophylaxis of cardiovascular events. 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. The submitted documentation indicates your doctor prescribed Vascepa for hypertriglyceridemia and prophylaxis of cardiovascular events. The medical records submitted indicate your triglyceride level is greater than 125 milligrams per deciliter but less than 500 milligrams per deciliter. You are not taking Vascepa as adjunct therapy to a statin medication. The Medicare approved compendia do not support the use of this 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: Unfavorable

You requested Tizanidine HCl 4 milligram tablets prescribed twice daily for spinal stenosis of the cervical region. 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 submitted documentation indicates your doctor prescribed Tizanidine HCl for spinal stenosis. The submitted medical records indicate the drug at issue was prescribed for fibromyalgia. The Medicare approved compendia do not support the use of the drug for any of these conditions. 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.