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

You requested coverage for Testosterone 2% gel via metered-dose pump prescribed for male hypogonadism. 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.Testosterone 2% gel is not included in the plans formulary. The prescriber has not addressed why all other alternative medications that are included in the plans formulary to treat the noted condition 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 Venofer 20 milligram/milliliter solution prescribed for iron deficiency anemia. 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 determined that the plan is not required to cover Venofer because it was a prescription vitamin product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations are excluded from coverage. Your plan does not offer supplemental (additional) 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: Favorable

At issue is Calquence 100 milligram capsule prescribed twice daily for your chronic lymphocytic leukemia. 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 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 plan's coverage criteria has been satisfied. The medical records support you were prescribed Calquence for your chronic lymphocytic leukemia after a recent relapse while on Imbruvica. A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Aimovig 140 milligram/milliliter injection 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.Aimovig is a brand biologic on Tier 4 of the plans formulary. There are no brand biologics of the same type on the lower cost sharing tiers. Therefore, this biologic is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Meloxicam 7.5 milligram tablets prescribed twice daily (180 tablets per 90 days) for rheumatoid arthritis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The part D plan has a quantity limit for Meloxicam of 30 tablets per 30 days, or one tablet per day. The documentation does not support the necessity for exceeding the maximum dose allowed by the plan. An exception to the quantity limit criteria has not been met. A physician reviewed your appeal and determined that the plan is not required to cover 180 tablets of Meloxicam per 90-day supply.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Regranex 0.01% gel prescribed for a non-pressure chronic ulcer of other part of right foot, with unspecified severity. 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 Regranex gel for a non-pressure chronic ulcer of other part of right foot, with unspecified severity. The Medicare approved compendia do not support the use of this biologic for your condition. A request was submitted for a supporting statement and medical records; however, no further documentation was received. As it cannot be determined that the biologic was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eszopiclone 2 milligram tablets prescribed to other sleep apnea. 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 regulations and Medicare approved compendia. Medicare approved compendia does not support the use of the drug for your conditionA physician reviewed your appeal and determined that the plan is not required to cover Eszopiclone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Restasis 0.05% eye emulsion, prescribed 1 drop to each eye, twice a day to treat dry eye syndrome. The Part D plan denied the request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Restasis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Saxenda 18 microgram/3 milliliter injection pen prescribed to treat obesity. The Part D plan denied your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level.Medicare excludes Part D coverage of drugs used for the treatment of weight gain or obesity. Therefore, we determined that the plan is not required to cover the Saxenda.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Ketoconazole 200-milligram tablet to treat transplant organ rejection. 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.The documentation satisfies the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500 milligram tablet. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The physician submitted a supporting statement. The prescriber statement indicates that Mycophenolate Mofetil is prescribed to treat systemic lupus erythematosus. However, the Medicare approved compendia do not support the use of this specific drug 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: Favorable

You requested Viokace 20,880-78,300 Units prescribed for pancreatic insufficiency. The Part D plan denied the request for a formulary exception. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is not on the plans formulary. The only other drugs on the plans formulary that are approved pancreatic enzyme products by the food and drug administration are Creon and Zenpep. It is documented by the prescriber that these drugs are not compatible with the enrollees gastrointestinal tube as the beads of the medication get stuck in her tube and prevent her from obtaining the full dosage needed. Therefore, this drug is eligible for a formulary exception.A physician reviewed your appeal and determined that the plan required to cover Viokace 20,880-78,300 Units.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Skyrizi 150 milligram dose kit prescribed for your palmoplantar pustulosis. 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 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 use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia does 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 requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tecfidera 240 milligram capsules prescribed for multiple sclerosis. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. The drug requested is not on the plans formulary. The medical records do not specifically address each formulary alternative and why they did not or would not work. A physician reviewed your appeal and determined that the plan is not required to cover Tecfidera.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested albuterol sulfate 0.083% nebulizer solution prescribed four times daily for shortness of breath. 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 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 record shows you are using your nebulizer to administer the albuterol for your shortness of breath and wheezing. However, this drug is eligible for coverage under Medicare Part B. Drugs administered at home using a nebulizer may be covered by Medicare Part B.We determined that the plan is not required to cover albuterol sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Zolpidem Tartrate ER 6.25 tablets prescribed for insomnia. 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. The documentation does not satisfy the plans prior authorization requirements. The prescriber has not sufficiently addressed the plans coverage criteria for 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

You requested a tiering exception for Creon 36,000 lipase units delayed release capsules prescribed for pancreatic insufficiency due to pancreatic 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.Creon is a biologic drug on Tier 3 of the plans formulary. There are no biologic drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Creon at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Cyclobenzaprine Hydrochloride 10 milligram tablets. 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 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 indicates that Cyclobenzaprine Hydrochloride has been prescribed to treat chronic neuropathic pain with muscle spasms in the residual limb after undergoing a below-the-knee amputation of the left leg in 2010. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of chronic neuropathic pain with muscle spasms. Therefore, the drug is being prescribed for a non-medically accepted indication and 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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Restasis 0.05 percent dropperette prescribed daily for keratoconjunctivitis sicca. 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. Restasis 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 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 a tiering exception request for Rocklatan 0.02-0.05% solution prescribed for treatment of the enrollees condition. 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.This drug is being provided by your 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.A physician reviewed your appeal and determined that the Part D plan is not required to provide a tiering exception for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Dupixent 300 milligram per 2 milliliter prefilled syringe prescribed for asthma. 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 Part D plan has prior authorization requirements that must be met before Dupixent will be covered. During this review, a prescriber statement and additional medical records were requested from the prescribing physician to address the plans specific coverage criteria. However, the prescribing physician did not respond to the request. Therefore, it is not possible to determine if the plans prior authorization requirements have been satisfied for the medication. A physician reviewed your appeal and determined that the plan is not required to cover the Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azelastine 0.15 percent nasal spray prescribed twice daily for vasomotor rhinitis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Azelastine nasal spray. A physician reviewed your appeal and determined that the plan is not required to cover the Azelastine nasal spray.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tymlos 80 microgram pen injector prescribed for postmenopausal osteoporosis. The Part D plan denied your request for a tier change request because Tymlos 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 record shows Tymlos is being prescribed for postmenopausal osteoporosis. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Tymlos 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 coverage for Repatha 140 milligram per 1 milliliter subcuataneous injection pen prescribed for hyperlipidemia. 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.Repatha is not included in the plans formulary. The prescriber has not addressed why all alternative medications that are included in the plans formulary to treat the noted condition 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 Desvenlafaxine Succinate 50 milligram ER tablets. 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 does not include medical records or evidence of a prescribed diagnosis. A request was submitted to your doctor for medical records to support a covered diagnosis. 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 Corlanor 5 milligram tablets prescribed twice daily for inappropriate sinus tachycardia and aortic valve insufficiency. 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 diagnoses of inappropriate sinus tachycardia and aortic valve insufficiency were given. At reconsideration a diagnosis of heart failure 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 Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Ozempic 0.25 milligram or 0.5-milligram pen injector prescribed for diabetes. The Part D plan denied your request for a tiering exception because Ozempic 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 Ozempic is a brand name Tier 3 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 Febuxostat 40 milligram tablet prescribed as directed to treat gout. 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 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 the Febuxostat.