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

At issue is Invokana, 100 milligram tablets prescribed for type 2 diabetes. The Part D Plan denied your request for a tiering exception because there were no other similar drugs 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. A physician reviewed your appeal and determined that the plan is not required to cover the Invokana at a lower cost tier.Invokana 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. If there are no brand name drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. Therefore, a tiering exception cannot be granted for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch to treat rheumatoid arthritis.  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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 3 milligram capsules prescribed three times daily for the enrollees condition. The Part D plan denied your request for a tiering exception because the prescriber did not address all alternatives were tried and failed. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Budesonide is a generic drug on Tier 4 of the plans formulary. Your doctor submitted a supporting statement. The statement said Azathioprine, Mesalamine, and Imuran could not help you. However, your doctor 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 the Nucynta 50 milligram tablet prescribed as directed for neuropathic pain. 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. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The record shows that your doctor prescribed the Nucynta treat your condition. Your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Nucynta because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Colestipol 5 gram packet prescribed for diarrhea. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Colestipol for diarrhea. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha SureClick 140 milligram/milliliter autoinjector pen prescribed as directed to treat atherosclerotic cardiovascular disease with hyperlipidemia. The Part D plan denied your request because the drug you requested is not included on your plans formulary. We received an expedited reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows that your doctor prescribed Repatha SureClick to treat your condition. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for Xtampza ER 18 milligram capsule sprinkle prescribed two capsules every 12 hours to treat chronic pain secondary to cervical spondylosis. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Xtampza to treat your chronic pain. The Medicare approved compendia do support the use of this drug for your condition. The plan requires prior authorization criteria be met before they will cover the requested drug. The documentation provided does not show you have satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Xtampza.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta, 20/10 milligram capsules taken once daily for a 90-day supply, which was prescribed to treat your pseudobulbar palsy. The Part D plan denied your request for a 90-day supply because Nuedexta is a specialty drug limited to a 30-day supply.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. Nuedexta is listed on your plans formulary as a tier 5 drug. This is the plans specialty drug tier. Your plan will only allow a 30-day supply at a time of specialty drugs. An exception to the quantity limit criteria cannot be granted. A physician reviewed your appeal and determined that the plan is not required to cover a 90-day supply of Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 1 milligram prescribed one capsule twice daily for kidney transplant anti-rejection. 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 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 verify information concerning your health history. Your prescriber confirmed your kidney transplant date and medication.Your medical record shows that Tacrolimus is prescribed for transplant anti-rejection after your kidney transplant on February 11, 2005. Medicare records show you were enrolled in Medicare Part A and B effective February 1, 2005, through February 29, 2008. The Medicare Part D Prescription Drug benefit does not cover drugs that are covered under the Medicare Part B. We determined that the plan is not required to cover Tacrolimus. Medicare Part B is responsible for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz XR 11 milligrams prescribed daily for dermatomyositis. The Part D plan denied your request because the Food and Drug Administration has not approved this drug for your diagnosis. 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 Xeljanz XR to treat your dermatomyositis. 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 Xeljanz XR. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 20 milligrams daily prescribed for major depression with co-occurring obsessive-compulsive disorder. The Part D plan denied your request because the drug did not meet prior authorization requirements. 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 Latuda for major depression with co-occurring obsessive-compulsive disorder. In review of the Medicare approved compendia, major depression with co-occurring obsessive-compulsive disorder is not a medically accepted indication for Latuda. This decision does not address the medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit. The prior authorization requirements were not considered since this drug was not prescribed for a medically accepted indication. Therefore, it does not meet the definition of a Part D drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is and exception request for Aranesp to be administered every other week. 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. Aranesp is not included on the plans formulary. The records did not specify the diagnosis the drug is prescribed to treat. The records also 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 Aranesp.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Leflunomide 20 milligram tablets prescribed daily for rheumatoid arthritis. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Leflunomide is a generic drug on Tier 3 of the plans formulary. You submitted a supporting statement. The statement said Leflunomide was prescribed to treat severe seropositive rheumatoid arthritis. Alternative drugs such as Remicade and Methotrexate have been tried and failed.  The prescriber has not indicated that you have tried all alternatives required by the Plan, or why the Plans lower tiered drugs would likely not be as effective as the requested drug.  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 Remicade Therapy 700 milligram intravenous infusion prescribed for the enrollees rheumatoid arthritis. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of rheumatoid arthritis. However, the enrollee does not 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: Unfavorable

At issue is Xifaxan, 550 milligram tablets prescribed for small intestinal bacterial overgrowth with constipation. The Part D plan denied your request because the enrollee did not have a covered condition. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Medical records were requested from the prescribing physician during this review, but not received.While the Medicare approved compendia list small intestinal bacterial overgrowth as an acceptable off-label use for Xifaxan, the record does not include any progress notes from the enrollees prescribing physician to validate a diagnosis of small intestinal bacterial overgrowth. Therefore, there is insufficient information to determine if the Xifaxan is being prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover the Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 21-10 milligram capsules prescribed as directed for pseudobulbar affect. The Part D plan denied your request because the medication is 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 records show you prescribed Nuedexta to treat pseudobulbar affect. However, the medical records submitted are not detailed enough to support a diagnosis listed in the Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Travasol 10% intravenous solution. 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 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 your doctor prescribed the medication for total parental nutrition in an enrollee with a permanent dysfunction of the gastrointestinal tract that is greater than three months. This drug is eligible for coverage under Medicare Part B. Medicare Part D does not cover total parental nutrition in an enrollee with a permanent dysfunction of the gastrointestinal tract.We determined that the plan is not required to cover Travasol 10% solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Divalproex Sodium ER 500 milligrams. 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.Divalproex Sodium ER is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated why other 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, 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

You requested Tadalafil 5 milligrams prescribed daily for benign prostatic hyperplasia. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.  We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. We asked your prescriber to send us information about your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why similar medications on the lower tiers would not work for you. We received the documentation and included it in our review.  Your medical records show your doctor prescribed Tadalafil 5 milligrams daily to treat your benign prostatic hyperplasia. However, the plan requires prior authorization criteria for this drug to be met before they will cover the requested drug. The documentation provided does not show you have satisfied the plan's coverage criteria.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 Xifaxan 550 milligram tablet three times daily for 14 days prescribed for intestinal bacterial overgrowth. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Xifaxan to treat your intestinal bacterial overgrowth. 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 the Xifaxan because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Urso 250 milligrams tablet prescribed for primary biliary cholangitis. The Part D plan denied your request to cover this drug at a lower tier cost. The plan indicated this is an approved non-formulary drug and cannot be provided at a lower tier cost. 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 Urso was prescribed; however, Urso is a non-formulary approved drug and is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz 10 milligrams prescribed as directed for Crohn's disease. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Xeljanz 10 milligrams to treat your Crohn's disease. 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 Xeljanz 10 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xtandi 40 milligrams, 4 capsules/day 120/30 to treat castration sensitive metastatic prostate cancer. This case was an auto-forward coverage determination.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 used for a medically accepted indication. This drug is at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the Xtandi.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vyvanse 30 milligrams daily prescribed for post-traumatic stress disorder. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Vyvanse to treat your post-traumatic stress disorder. However, the Medicare approved compendia does 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 Vyvanse