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

At issue is Xarelto 20 milligram tablets once per day for acute embolism and thrombosis of unspecified deep veins of unspecified lower extremities. The Part D Plan denied your request for a tiering exception because the drug is covered at the lowest cost-sharing Tier and no other drug of the same type, to treat the same condition, is on a lower cost-sharing Tier. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The prescriber indicated that the enrollee required treatment with Xarelto due to being stable on the drug and no change should be made as it could result in a significant adverse effect. Xarelto is a Brand drug on Tier 3 of the plans formulary. The plans formulary includes other Brand medications on lower Tiers that are the same class as Xarelto. Your physician did not address why these other medications were not tried or why he feels they might result in an adverse effect. 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 Virtussin AC liquid prescribed to treat chronic cough. The Part D Plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed for symptomatic relief of cough and colds 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 Repatha Sureclick, 140 milligrams prescribed one injection two times daily for hyperlipidemia. The Part D plan denied coverage because you had not tried the drug ezetimibe plus one high-intensity statin drug (atorvastatin 40 milligrams or rosuvastatin 20 milligrams per day or more) or, if you could not tolerate a high-intensity statin, you tried one statin at the highest dose you could tolerate; and (3) you were not able to reach an LDL goal of less than 100 on the statin drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your medical records show your doctor prescribed Repatha Sureclick to treat your hyperlipidemia. The Medicare compendia approve the use of Repatha Sureclick for your condition. Your doctor states that you have been on Repatha since November 2018, with positive response. Your doctor has confirmed you have tried Lescol, 80 milligrams, Crestor 20 milligrams, Lipitor, 40 milligrams, and Zetia, 10 milligrams without success of lowering your low-density lipoprotein levels.  However, the documents do not indicate combination drugs of Ezetimide plus a high dose statin or an intolerance to high dose statin drugs and a low-density lipoprotein under 100 on the statin drug.  A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira Pen 40 milligram/0.4 milliliters injection prescribed for Rheumatoid Arthritis. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. 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. Humira is a brand drug on Tier 5, also known as the Specialty Tier, of the plans formulary. If a plan maintains a Specialty Tier, the plan may design its exception process so that drugs placed in the Specialty Tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the Specialty Tier from the tiering exception process. Therefore, this drug is not eligible for a tiering exception.This drug is being provided by your plan at the cost sharing level of the Specialty Tier. Specialty Tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dupixent 300 milligrams prescribed as directed for bullous pemphigoid. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Dupixent 300 milligrams to treat your bullous pemphigoid. 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 Dupixent 300 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Leukine 250 mcg injection prescribed as directed to treat metastatic prostate cancer. 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 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 the enrollees 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 Leukine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate mofetil 500 milligram tablets prescribed as directed for Stiff-person syndrome. The Part D plan denied your request because the drug might be covered by Medicare Part B. The Part D plan also 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 medical records show the doctor prescribed Mycophenolate mofetil to treat Stiff-person syndrome. The documentation does not show that the medication was prescribed following a Medicare-covered organ transplant. Therefore, the drug would not be covered under Medicare Part B, and is eligible for consideration of Medicare Part D coverage. However, the Medicare approved compendia do not support the use of Mycophenolate mofetil for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ajovy injection prescribed for chronic migraines. The Part D plan denied your request because the documentation did not support an off-formulary exception since not all preferred drugs were previously tried. 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 physician submitted a supporting statement. The prescriber statement shows the physician had prescribed Ajovy to treat migraines. The Medicare approved compendium does support the use of this drug for migraines. However, the records do not show why preferred alternatives on the plans formulary for the same condition have not been tried. Specifically, the documentation does not show that the enrollee has tried all formulary alternatives, or why the enrollee cannot take them.A physician reviewed your appeal and determined that the plan is not required to grant a non-formulary exception for the Ajovy.
Appeal type: Prescription Drug
Decision: Favorable

You requested Premarin 0.625 milligrams prescribed daily for prevention of postmenopausal osteoporosis. The Part D plan denied your request because the 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 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 Premarin for prevention of postmenopausal osteoporosis. The Medicare approved compendium supports the use of this drug for this condition. The prescribers statement supports the diagnosis and the fact that the drug is high risk. The documentation provided shows the prior authorization criteria has been met. Therefore, the drug can be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is required to cover Premarin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Effer-K 20 milliequivalents to treat hypokalemia. The Part D Plan denied the request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. The Medicare approved compendia indicates that this drug has not been found by the United States Food and Drug Administration to be safe and effective, and the drug product labeling has not been approved. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Myrbetriq 50 milligram tablets prescribed daily for urinary bladder outlet obstruction, urge incontinence, nocturia, and neurogenic bladder related to Parkinsons disease. The Part D plan denied your request for a tiering exception because Myrbetriq is a brand name Tier 4 brand 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 record shows Myrbetriq is being prescribed for urinary bladder outlet obstruction, urge incontinence, nocturia, and neurogenic bladder related to Parkinsons disease. The Medicare approved compendium, supports the use of the requested drug for your condition. 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

At issue is Rytary ER 36.25-145 milligrams prescribed as directed for Parkinsons disease. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Rytary ER 36.25-145 milligrams is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Rytary ER 36.25-145 milligrams because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Repatha Sureclick Auto injector, 140 milligrams/milliliter prescribed one injection every two weeks for hyperlipidemia. The Part D plan denied coverage because the requested drug is not on your plans formulary. The information submitted did not show that the criteria for a formulary exception had been met. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your medical records show your doctor prescribed Repatha Sureclick to treat your hyperlipidemia. Your plans formulary does not include Repatha for your condition. Additionally your doctor has not shown you have tried all the covered Part D drugs on any tier of your plan's formulary and determined that they would not be as effective for you as the non-formulary drug and/or would have adverse effects.A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick because there are no lower tiered biologic drugs of the same type. Therefore, a formulary exception cannot be allowed.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dysport 1500 units injected in multiple places prescribed every two months for contractures. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee has the Dysport injections given within the physicians office in multiple locations every two months. 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 Dysport. 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 Androderm 2milligrams/24 hours transdermal patch prescribed for the treatment of male erectile dysfunction. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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 the enrollees 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 Androderm 2milligrams/24 hours transdermal patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Promethazine 25 milligrams for the treatment of chronic migraine headaches. The Part D plan denied your request because the drug was ordered for a non-medically accepted indication. We received an expedited 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. The medical records show Promethazine was prescribed for your condition. However, the Medicare approved compendia do not support the use of this drug for headaches. A physician reviewed your appeal and determined that the plan is not required to cover the requested Promethazine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Auryxia to treat iron deficiency anemia in chronic kidney 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 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.Drugs prescribed for use as vitamins and minerals 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 Combivent Respimat 100 microgram prescribed four times daily 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 physicians representative submitted a statement and medical records. The medical records show the physician had prescribed Combivent Respimat to treat your chronic obstructive pulmonary disease.  The Medicare approved compendium support the use of the requested drug for your condition.However, the records do not show why you cannot take other drugs on your plans formulary for your condition. Specifically, Bevespi Aerosphere HFA aerosol inhaler, Breo Ellipta powder for inhalation, and Symbicort HFA aerosol inhaler.A physician reviewed your appeal and determined that the plan is not required to cover Combivent Respimat.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lumigan 0.01 percent eye solution prescribed as directed for open angle glaucoma. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Lumigan 0.01 percent eye solution is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Lumigan 0.01 percent eye solution because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Restasis eye drops prescribed as directed for chronic dry eyes and epithelial dystrophy. 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. We also researched Medicare systems and reviewed the enrollment data available. The record shows you were prescribed Restasis eye drops for chronic dry eyes and epithelial dystrophy. 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 provide the Restasis eye drops at a lower cost sharing level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Voriconazole 200 milligram vial prescribed daily for mycotic corneal ulcer, right eye. The Part D plan denied your request because the drug is not covered under the plan. 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 also researched Medicare systems and reviewed the enrollment data available.We determined that the plan is not required to cover Voriconazole because it is not covered under the Part D plan. The drug is in bulk powder form and Medicare Part D does not cover bulk powders. Your plan does not offer coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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

At issue is Lidocaine-Prilocaine Cream 2.5/2.5/% to treat Neuropathic pain, lichen sclerosis in the vaginal area. The Part D plan denied the request stating that the provided diagnosis is a non-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 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 the enrollees condition. No medical records were provided. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sivextro 200 milligram tablets prescribed twice daily for pulmonary mycobacterial infection. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Sivextro to treat your multi-drug resistant mycobacterial abscess pulmonary infection. 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 Sivextro.