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

At issue is Bevespi Aerosphere 4.8 microgram/1-Actuation-9 microgram/1-Actuation inhalation powder prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. 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.Bevespi Aerosphere 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Divalproex Sodium ER 500 milligram tablets prescribed daily for bipolar II disorder. The Part D plan denied your request for a tier change request because Divalproex Sodium ER 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 Divalproex Sodium ER is being prescribed for bipolar II disorder. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Divalproex Sodium ER is a generic Tier 4 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 Trulicity pen injector to treat diabetes. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration requestWe 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. Trulicity pen injector is a brand 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, a tiering exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Trulicity pen injector.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prior authorization coverage and a lower cost-sharing tiering exception for Premarin 1.25 milligram tablets. The Part D plan denied coverage because the prior authorization requirements were not met. The plan denied the lower cost tiering exception stating that the documentation did not support that the enrollee had tried and failed the formulary alternatives. 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 medical records submitted at reconsideration support that the Premarin has been prescribed for post-menopausal estrogen replacement therapy. The prescriber notes that the enrollee is receiving estrogen replacement therapy to help with depression and anxiety symptoms. However, the Part D plans prior authorization guidelines do not include the management of depression and anxiety symptoms as one of the indications for estrogen replacement therapy. The medical records do not indicate that the enrollee is receiving estrogen replacement therapy for one of the plans accepted indications.Therefore, the prior authorization guidelines for coverage of the Premarin have not been met. Furthermore, since the documentation does not support coverage of the Premarin, a lower cost tiering exception cannot be considered.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 Otezla 30 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for a lower cost-sharing tier. 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.Otezla is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier 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

You requested a tier exception for Viibyrd 20 milligrams prescribed for severe anxiety with depression. The Part D plan denied your request for a tiering exception because Viibyrd is a brand name Tier 4 drug and the lower cost-sharing tiers only contain generic alternative drugs. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The record shows Viibyrd is being prescribed for severe anxiety with depression. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Viibyrd is a brand name Tier 4 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Veltassa 8.4 gram packet prescribed three times weekly for hyperkalemia. 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 asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested. The medical records show you prescribed Veltassa to treat the enrollees hyperkalemia. The Medicare approved compendia do support the use of this drug for this condition. The plan requires prior authorization criteria be met before covering this 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 Veltassa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 5 milligram capsules to treat nausea and vomiting with a medical history of chronic pain syndrome, spinal stenosis, paraplegia, diabetes, and radiculopathy of the cervical and lumbar regions. 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 prevention of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 a tiering exception request for Methotrexate 2.5 milligram tablets prescribed daily to treat the enrollees condition. The Part D plan denied the 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 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.Methotrexate 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

At issue is Losartan potassium 50 milligram tablets prescribed as directed for hypertension. 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. Losartan potassium is a generic drug on Tier 1 of the plans formulary. Tier 1 drugs are not eligible for a tiering exception because they are already classified as the lowest tier on the plans formulary. 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 Cyanocobalamin solution 1000 micrograms per milliliter treat deficiency of other specified B group vitamins. 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.Vitamins and minerals are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vimpat 150 milligram tablets prescribed for seizures. The Part D plan denied your request for a tier change request because Vimpat 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 Vimpat is being prescribed for seizures. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Vimpat is a brand name Tier 4 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 Buprenorphine 10 microgram/hour patch prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue was covered as a formulary exception and was not eligible 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.Buprenorphine patch is a non-formulary brand drug. 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 Imuran 50 milligram tablet to treat nonspecific interstitial pneumonia. 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 Vascepa 1 gram capsules prescribed for hypertriglyceridemia. The Part D plan denied your request for a tiering exception for this covered drug at a lower cost tier. 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 documentation shows Vascepa is a brand drug on Tier 2 of the plans formulary. There are no other drugs of the same type on the lower cost sharing tiers to treat the enrollees condition(s). 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 Prolia 60 milligram/1 milliliter syringe prescribed to treat the enrollees condition. The Part D plan denied the 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 the case file carefully. We reviewed all documentation submitted.Prolia is a biologic on Tier 4 of the plans formulary. There are no other 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 Pregabalin 75 milligram capsules to treat the diagnosis of pruritus affecting the scalp and groin. 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 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 prevention of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 Voriconazole 200 milligram tablets prescribed for other myelodysplastic syndromes. The Part D plan denied your request because the drug was not prescribed for 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 records submitted at the reconsideration level.The submitted documentation indicates your doctor originally prescribed Voriconazole for other myelodysplastic syndromes. Your doctor submitted a supporting statement and medical records to indicate the drug was prescribed for prophylaxis of aspergillosis. This is an off-label use for the drug at issue. The Medicare approved compendia do not contain citations to 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

You requested Methylphenidate hydrochloride 10 milligram tablets prescribed as directed. 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. We asked the prescriber to send us information regarding the enrollees condition. We asked for medical records to show why the enrollee needs this medication. We did not receive the documentation requested.The prescriber statement submitted to the plan shows the enrollee was prescribed Methylphenidate hydrochloride for major depressive disorder. The prescriber statement submitted at reconsideration now includes a diagnosis of attention-deficit hyperactivity disorder. No medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Methylphenidate hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Methylphenidate Hydrochloride, 5 milligram tablets The Part D plan denied the request stating that the medication was 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 medical records submitted at reconsideration support that Methylphenidate Hydrochloride has been prescribed to treat the enrollees cognitive impairment associated with multiple sclerosis and attention deficit disorder. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of 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 cover the Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Testosterone 1.62% gel. The Part D plan denied coverage because there was not confirmation of a diagnosis of primary hypogonadism or hypogonadotropic hypogonadism, which is a requirement by the 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. The prescriber statement submitted at reconsideration states that the enrollee was diagnosed with hypogonadotropic hypogonadism in 2012 and has been on testosterone replacement for over eight years. Also submitted at reconsideration are progress notes from an endocrinologist visit in 2015 that validate the enrollee is being treated for hypogonadotropic hypogonadism. Therefore, the medical records do confirm a diagnosis of hypogonadotropic hypogonadism and the plans prior authorization requirement has been satisfied.A physician reviewed your appeal and determined that the plan is required to cover the Testosterone.
Appeal type: Prescription Drug
Decision: Favorable

At issue is NovoLog Flexpen 100 units/milliliter prescribed 25 units prior to each meal for diabetes mellitus. The Part D plan denied your request because the dosage prescribed is very high and per Medicare rules is not covered. 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 NovoLog Flexpen 25 units prior to each meal to treat your diabetes Mellitus. The Medicare approved compendia allows up to the maximum dispensing limit of 2.4 milliliters per day, which is a maximum of 240 units per day. A physician reviewed your appeal and determined that the plan is required to cover NovoLog Flexpen because the dosage per day is within Medicare guidelines.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Retacrit 40, 000 unit injection solution prescribed for anemia due to antineoplastic chemotherapy. 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 requested a prescriber statement explaining why the enrollee cannot take the other drugs on the plans formulary for their condition. The documentation received shows the enrollee tried Procrit. However, the results of the drug trial were not listed. 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 Retacrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate ER 12.5 milligram tablets prescribed for insomnia. 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 and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.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.A physician reviewed your appeal and determined that the plan is not required to cover Zolpidem Tartrate ER 12.5 milligram tablets because the documentation did not support an off-formulary exception.