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

At issue is Nucynta Extended Release 150 milligram 12-hour tablet prescribed for fibromyalgia. The Part D plan denied coverage because this request for coverage was based on the Concurrent Opioid Benzodiazepine Drug Utilization Review criteria. It could not be approved at this time. You must meet our criteria for this drug to be covered by your plan. 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. Nucynta Extended Release is prescribed to treat your fibromyalgia. The plan requires prior authorization and supporting medical records before they will consider covering 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 Nucynta Extended Release because the coverage requirements have not been met per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Shingrix 50 mcg/0.5 ml to prevent Herpes Zoster.   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.Shingrix 50 mcg/0.5 ml is a biologic drug on Tier 3 of the plans formulary. There are no biologic drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alosetron 0.5 milligram tablet prescribed two tablets twice daily for diarrhea. 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. Your medical records show your doctor prescribed Alosetron to treat your diarrhea. Your medical records note a history of both irritable bowel syndrome and ulcerative colitis. 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 prescriber statement submitted indicates that your prescriber has determined your diarrhea is not related to irritable bowel disease. 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 Alosetron 0.5 milligram tablet. We cannot consider a quantity limit exception for a drug we cannot cover.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Hetlioz 20 milligram capsules. 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.  The plan has prior authorization requirements for the coverage of Hetlioz. However, the submitted documentation is insufficient to determine if those prior authorization requirements have been satisfied. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lumigan 0.01% prescribed for an unknown diagnosis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. The record shows the prescriber requested Lumigan 0.01% solution, 3 milliliters per 30 days. Relevant medical records were requested but not provided. There were no medical records to support the medical necessity for this drug.A physician reviewed your appeal and determined that the plan is not required to cover the Lumigan. There was insufficient evidence to find the Lumigan medically necessary.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 9 milligrams prescribed as directed for microscopic colitis. 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. This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that a tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Miconazole-zinc oxide-petrolat prescribed as directed for a yeast infection. The Part D plan denied the request for 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.The prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the plans formulary alternatives. We did not receive the documentation requested.Your medical records show your doctor prescribed Miconazole-zinc oxide-petrolat 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 Miconazole-zinc oxide-petrolat because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tradjenta 5 milligram tablets prescribed daily for diabetes. 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. Tradjenta is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec 75 milligram tablets to treat chronic migraines. The Part D plan denied your request because the documentation did not support an off-formulary 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. 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 Nurtec. A physician reviewed your appeal and determined that the plan is not required to cover Nurtec because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Calcitriol 0.25-microgram capsule prescribed one capsule three times a week to treat the enrollees hyperparathyroidism secondary to renal dysfunction. The Part D plan denied the request for a tiering exception because there are no generic drugs of the same type on the lower tiers of the plans formulary to treat the same condition. 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.Calcitriol was prescribed by your doctor to treat your hyperparathyroidism. The Medicare approved compendia support the drug is used to treat your condition. Calcitriol 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. Calcitriol is being provided to you at the lowest cost-share amount allowed by your plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 3 milligram capsule prescribed for treatment of Bipolar 1 disorder. 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. Your doctor prescribed Vraylar 3 milligram capsule for your Bipolar 1 disorder. Vraylar 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.A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for Vraylar because a tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Lidocaine 5% patches for the treatment of mononeuropathy and sciatica. The Part D plan your request for reimbursement because the drug was denied by the plan for being prescribed for 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 documentation submitted at reconsideration indicates the Lidocaine patches were prescribed to relieve pain due to mononeuropathy and sciatica. However, the Medicare approved compendia do not contain any citations to support the use of the medication, as prescribed, for the noted conditions. 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 reimburse the cost of the Lidocaine patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tirosint 200 microgram capsules. The Part D plan denied your request because the medication was not included in the plans formulary and the documentation did not support an off-formulary 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. The documentation supports that Tirosint has been prescribed to treat the enrollees postprocedural hypothyroidism. However, the prescriber has not sufficiently addressed why all alternative drugs included in the plan to treat this condition have been tried and failed or would likely not be as effective as the requested drug or would likely cause adverse reactions or other harm. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doxepin Hydrochloride 5% Cream. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The documentation indicates that Doxepin Hydrochloride 5% Cream was prescribed to treat chronic pain syndrome and myalgia. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s). Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Doxepin Hydrochloride 5% Cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 20 milligram oral tablet  for the prophylaxis of cerebrovascular accident in an enrollee with atrial fibrillation.   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.Xarelto 20 milligram oral tablet 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. Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vascepa 0.5-gram capsule prescribed four capsules twice a day for the enrollees hypercholesterolemia. 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. The documentation supports the drug was prescribed for the enrollees diagnosis of hypercholesterolemia. However, Medicare approved compendia do not support the use of this drug for your condition. 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 Dupixent solution 300 milligram/2 milliliter prefilled syringe prescribed for atopic dermatitis. 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. 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 documentation provided shows Dupixent was supplied by the prescriber and administered to the enrollee in the prescribers office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover Dupixent. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Orilissa 200 milligram tablets prescribed as directed to treat endometriosis. The Part D plan denied the request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The 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. 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 coverage for Sildenafil Citrate 20 milligram tablets. The Part D plan denied the request because the plans prior authorization requirements were not met. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The documentation submitted at reconsideration indicates that Sildenafil Citrate has been prescribed in the treatment of the enrollees pre and post capillary pulmonary hypertension,WHO group II, with underlying cardiomyopathy. However, the Medicare approved compendia do not contain any citations to support the use of the medication, as prescribed, for the treatment of the noted condition. Therefore, the requested 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 Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Sildenafil citrate 20 milligram tablet prescribed as directed to treat pulmonary arterial hypertension. 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.Sildenafil citrate is a generic drug on Tier 3 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Myrbetriq ER 50 milligram tablet prescribed as directed to treat overactive bladder. 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.Myrbetriq ER 50 milligram tablet 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ketorolac tromethamine solution 60milligrams\2 milliliters  intramuscular, prescribed as directed to treat G43.109 - Migraine with aura, not intractable, without status migrainosus. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an auto-forwarded 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 that your doctor prescribed Ketorolac tromethamine solution 60milligrams\2 milliliters  intramuscular, to treat your condition. 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 Saxenda 18 milligrams/3 milliliters injection pen prescribed daily for morbid obesity. The Part D plan denied your request because this type of drug is excluded from Part D coverage. 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 determined that the plan is not required to cover Saxenda because drugs used for weight loss 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: Unfavorable

You requested Ondansetron 4 milligrams prescribed as needed for nausea due to use of oral antibiotics. The Part D plan denied your request because the provided diagnosis 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 Ondansetron 4 milligrams as needed to treat your nausea due to use of oral antibiotics. 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 Ondansetron 4 milligrams because it was not prescribed for a medically accepted indication.