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

At issue is Zeposia 0.92-milligram capsules prescribed as directed. 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 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.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 Codeine Sulfate 60-milligram tablet to treat pain related to spinal stenosis, lumbar region without neurogenic claudication. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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 Mesalamine 400-milligram Capsule Delayed Release to treat ulcerative colitis, unspecified without complications. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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

You requested Diclofenac Sodium 1 percent gel prescribed as directed for chronic pain syndrome. 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 shows your doctor prescribed Diclofenac Sodium to treat your chronic pain syndrome. 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 Diclofenac Sodium.
Appeal type: Prescription Drug
Decision: Favorable

You requested Cyclosporine 25 milligram capsule prescribed to prevent transplant rejection after a kidney transplant. 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 record shows the enrollee had a kidney transplant that was not performed while covered under Medicare. Therefore, the drug at issue is eligible under Part D drug benefits. The documents support the use of Cyclosporine for the prevention of a transplant rejection in an enrollee that has undergone a kidney transplant.  A physician reviewed your appeal and determined that the plan is required to cover Cyclosporine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz 5-milligram tablet to treat rheumatoid arthritis. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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 a request for coverage of Forteo 620 microgram per 2.48 milliliter subcutaneous injection pen prescribed for idiopathic osteoporosis with a high risk for fractures. 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 coverage criteria for this medication. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Loratadine 10 milligram oral tablet prescribed daily for allergic conjunctivitis of the right eye. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. We received the documentation and included it in our review.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Loratadine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 600 microgram/2.4 milliliter pen injector prescribed as directed for age-related osteoporosis without current pathological fracture. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.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.Your medical records show your doctor prescribed Forteo to treat your age-related osteoporosis without current pathological fracture. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Forteo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pennsaid 2% Solution prescribed for trochanteric bursitis of right hip, iliotibial band syndrome of right leg, and lesion of sciatic nerve of unspecified lower limb. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we reviewed the appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.The documentation shows the doctor prescribed Pennsaid 2% Solution to treat the enrollees trochanteric bursitis of right hip, iliotibial band syndrome of right leg, and lesion of sciatic nerve of unspecified lower limb. However, the Medicare approved compendia do not support the use of this drug for these conditions.A physician reviewed this appeal and determined that the plan is not required to cover Pennsaid 2% Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Pulmicort Flexhaler 180 microgram per actuation inhalation powder prescribed for asthma. 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. Pulmicort Flexhaler is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all of the formulary alternatives included in the plan to treat the enrollees 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

At issue is a request for coverage of Morphine Sulfate ER 10 milligram extended release 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 Morphine Sulfate ER tablets have been prescribed on an as needed basis for the treatment of complex regional pain syndrome of the right upper limb. However, as outlined in the Medicare approved compendia, Morphine Sulfate ER is indicated for the management of chronic severe pain in patients requiring a long-term daily around-the-clock opioid analgesic. Since the drug is being taken as needed, it does not support the need for a long-term daily around-the-clock opioid analgesic. 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 the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dexmethylphenidate 40-milligram Extended Release Tablet to treat attention deficit hyperactivity disorder. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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 Acyclovir Cream 5% prescribed for shingles. The Part D plan denied your request due to the drug is non-formulary. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, your physician has not indicated why all other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Acyclovir Cream 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Uptravi 1200-milligram tablet. At initial determination and redetermination the diagnosis of pulmonary hypertension was given. The Part D plan denied the request. The requested drug is not on the plans formulary. 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.At reconsideration a diagnosis of pulmonary arterial hypertension was given. 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

You requested Lidocaine Hydrochloride urethral/mucosal 2 percent gel prescribed as directed for postherpetic neuralgia. 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 shows your doctor prescribed Lidocaine Hydrochloride urethral/mucosal 2 percent gel to treat your postherpetic neuralgia. 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 Lidocaine Hydrochloride urethral/mucosal 2 percent gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram prescribed three time daily for irritable bowel syndrome. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your medical records show your doctor prescribed Xifaxan to treat your irritable bowel syndrome. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Xifaxan. You have previously used the medication and have a recurrence of symptoms. In addition, you have already received an initial 14-day course of treatment and two additional 14-day courses. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Oxcarbazepine 150-milligram tablet to treat the enrollees condition.   The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Oxcarbazepine 150-milligram tablet 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

You requested Adderall 20 milligram tablet for bipolar disorder. 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 shows your doctor prescribed Adderall to treat bipolar disorder. However, the Medicare approved compendia do not support the use of this drug for your conditions. A physician reviewed your appeal and determined that the plan is not required to cover Adderall.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 5 milligram tablet prescribed for muscle spasm of the back. 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. Your prescriber indicates they prescribed Cyclobenzaprine Hydrochloride 5 milligram tablet for chronic muscle spasm condition. We requested additional documentation, including medical records, to support the diagnosis but did not receive a response. Medicare approved compendia do not support the use of this drug for chronic muscle spasm conditions.  A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidoderm 5% patch prescribed for polyneuropathy. 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 shows your doctor prescribed Lidoderm 5% patch to treat your unspecified polyneuropathy and muscle weakness. 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 Lidoderm.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Xiidra 5% eye drops prescribed for keratoconjunctivitis sicca. 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 did not include a supporting statement. A request for information was sent to your physician. Your physician submitted medical records and a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Xiidra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulicity 1.5 milligrams per 0.5 milliliter pen prescribed once per week for type 2 diabetes. 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 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.Trulicity 1.5 milligrams per 0.5 milliliter pen is a biologic drug on Tier 3 of the plans formulary. There are no biologic drugs of the same type on the lower cost sharing tiers. 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

At issue is Anoro Ellipta 62.5-25-micrograms/Inhalation to treat chronic obstructive pulmonary disease. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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 Memantine 10 milligram tablets prescribed as directed. 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. Memantine is a generic drug on Tier 2 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Creon 36,000 unit capsules prescribed as directed. 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. Creon is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.