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

At issue is Lidocaine 5 percent topical patch prescribed daily for chronic lower back pain and intermittent radiculopathy. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 Lidocaine 5 percent topical patch prescribed daily for chronic lower back pain and intermittent radiculopathy. In review of the Medicare approved compendia, chronic lower back pain and intermittent radiculopathy are not medically accepted indications for Lidocaine 5 percent topical patch as prescribed. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Lidocaine 5 percent topical patch at issue. 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. The plan is not required to cover the Lidocaine 5 percent topical patch at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methotrexate 2.5 milligram, Metformin hydrochloride 500 milligram, Atorvastin calcium 40 milligram, and Levothyroxine 88 micrograms prescribed for unknown diagnosis. The plan provided documentation showing the claims were allowed at the time of purchase for the plans cost share amount. The enrollee is requesting reimbursement for the amount of copay requested at the time of purchase. We received a reconsideration request.We conducted an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you purchased Methotrexate, Metformin hydrochloride, Atorvastin calcium, and Levothyroxine from an out-of-network pharmacy for an amount that is less than or equal to the required copayment amount. The information provided includes a letter from the plan dated February 04, 2021 indicating there were changes made to your prescription coverage for the Methotrexate, Metformin, and Atorvastin, and the claims were reprocessed to calculate correct copay amounts. We determined that the plan was correct in the calculation of copay and is not required to provide additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Opsumit 10 milligrams prescribed one tablet daily for pulmonary hypertension. Your Part D plan denied the appeal because Opsumit is a Specialty Tier drug on Tier 5 and is not eligible for a cost-share tiering 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 records submitted at the reconsideration level. The record shows your doctor prescribed Opsumit to treat your pulmonary hypertension. Your plans formulary shows that Opsumit is a Tier 5, Specialty Tier drug. Medicare does not allow a cost-sharing tiering exception for a Specialty Tier drug.A physician reviewed your appeal and determined that the plan is not required to cover Opsumit because a Specialty Tier drug is not eligible for a cost-share tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Miralax 17 gram powder pack prescribed for Hirschsprungs. The Part D plan denied the request because the requested medication did not meet the criteria of Medicare Part D drug. We received a request for reconsideration. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.We determined that the plan is not required to cover the Miralax because this drug is excluded from coverage under Medicare Part D. Medicare rules state that non-prescription or over the counter drugs are not eligible for Part D coverage. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate HFA inhaler prescribed as directed for Covid-19. The Part D plan denied your request for a tiering exception because there were no generic drugs of the same type on the lower cost sharing tiers. 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.Albuterol Sulfate HFA inhaler is a generic 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.Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil 50 milligram tablets prescribed as directed for erectile dysfunction. The Part D plan denied your request because drugs being used for the treatment of erectile dysfunction are excluded from coverage by Medicare Part D. 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. We determined that the plan is not required to cover Sildenafil. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

You requested Prolastin-C 1000 milligrams/20 vial prescribed for Alpha-Antitrypsin Deficiency with Emphysema . 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 information submitted at the reconsideration level. The medical record shows the physician prescribed Prolastin C for Alpha-Antritrypsin Deficiency with Emphysema. For coverage of Prolastin-C, your Part D plan requires a baseline (pretreatment) Alpha-Antitrypsin serum concentration of less than 80 milligrams/deciliter. The clinical note dated May 1, 1992, includes a baseline serum concentration level below 80.We determined that the plan is required to cover Prolastin-C. The Medicare rules above have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Janumet Extended Release 1000 milligrams/100 milligrams prescribed once daily for antidiabetic therapy. The plan denied the appeal because there are no brand name drugs in the lower cost-sharing tiers that treat your condition. 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 Janumet Extended Release is being prescribed for your antidiabetic therapy. A Medicare approved compendium supports the use of the requested drug for your condition. Janumet is a brand name drug on Tier 3 of your plan's formulary. 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 cost-sharing tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Janumet Extended Release because there are no brand name drugs in the lower cost-sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ztlido 1.8% patch prescribed as directed to treat chronic back pain. 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 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 the Ztlido patch to 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 Ztlido patch because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligram per 2-milliliter injection to treat atopic dermatitis. 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. 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

At issue is a tiering exception request for Eliquis 2.5 milligram tablets to treat unspecified 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 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.Eliquis 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: Favorable

You requested Morphine Sulfate Extended Release 15 milligram tablets prescribed twice daily for psoriatic arthropathy. The Part D plan denied your 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. Your medical records show your doctor prescribed Morphine Sulfate Extended Release to treat your condition. A physician reviewed your appeal and determined that the plan is required to cover Morphine Sulfate Extended Release. Medical records and prior authorization forms support the prior authorization criteria has been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium gel 1%. The Part D plan denied coverage because there was insufficient documentation to support that the prior authorization criteria were met. 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 records submitted at the reconsideration level. The physician submitted a supporting statement. The prescriber statement indicates the physician had prescribed Diclofenac Sodium for chronic low back pain due to transverse myelitis and myelopathy.However, the plan requires documentation that the enrollee has osteoarthritis pain in joints susceptible to topical treatment; such as, feet, ankles, knees, hands, wrists, or elbows. The documentation available for review 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 Diclofenac Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eszopiclone 2 milligram tablet to treat insomnia.   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

At issue is Metaxalone 800 milligram tablets prescribed to treat low back 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. 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. Metaxalone is a non-formulary drug. The medical records do not include why the plans formulary alternatives are not medically appropriate to treat the enrollees condition. The prescriber did not address 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 Metaxalone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Isosorbide Dinitrate 20 milligram tablets prescribed twice daily for angina pectoris and 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 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.Isosorbide Dinitrate 20 milligram tablets is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated if all alternatives required by the Plan have been tried and failed, 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 Flomax 0.4 milligram capsules. 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 Flomax at a lower cost tier.Flomax is a brand drug on Tier 3. There are no brand drugs of the same type on the lower cost sharing tiers. If there are no brand 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 Flomax.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed as directed for non-24 hour sleep/wake cycle. 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 physician submitted a supporting statement. However, the plan requires documentation of laboratory results; such as, cortisol or melatonin levels, or an actigraphy over a several week interval. The documentation available for review 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 Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligrams prescribed two tablets twice daily for Sicca syndrome and interstitial lung disease without evidence of systemic sclerosis. The Part D plan denied your request because the diagnosis provided does not meet the requirements of a Food and Drug Administration 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. Your medical records show your doctor prescribed Mycophenolate Mofetil to treat your Sicca syndrome and interstitial lung disease without evidence of systemic sclerosis. 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 Mycophenolate Mofetil because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipratropium-Albuterol Nebulizer Solution prescribed for chronic obstructive pulmonary disease. 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 performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. We determined that the drug is eligible for Part B coverage. Therefore, the drug cannot be considered for payment under the Part D benefit.Your medical records show your doctor prescribed Ipratropium-Albuterol to treat your condition. However, the drug is administered through your nebulizer at home and therefore it is covered under Part B.A physician reviewed your appeal and determined that the plan is not required to cover the Ipratropium-Albuterol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligram tablets prescribed daily for polymyositis. The Part D plan denied your request because it 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 Mycophenolate Mofetil 500 milligram tablets daily to treat your polymyositis. 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. The plan has approved a 3 month transition fill of your medication. This denial applies after the 3 month authorization expires. A physician reviewed your appeal and determined  that the plan is not required to cover Mycophenolate Mofetil 500 milligram tablets because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid (Levothyroxine Sodium) 88 microgram tablets prescribed daily for hypothyroidism. You asked the Part D plan to provide a tiering 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. We also researched Medicare systems and reviewed the enrollment data available.The records show Synthroid is being prescribed for hypothyroidism. The Medicare approved compendia support the use of the requested drug for your condition. Synthroid is a brand name drug that is on Tier 2 of your plan's formulary. Your doctor submitted a prescriber statement indicating that you tried Levothyroxine Sodium. This drug did not control your condition. However, the plan formulary includes other brand drugs on lower tiers that could be used to treat your condition. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit. Therefore, the plan is not required to grant a tiering exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Insulin Lispro Kwikpen prescribed for type 2 diabetes. 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 requested drug is not on the plan's formulary. 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 Diclofenac Epolamine 1.3% patch prescribed as directed for unspecified rotator cuff tear or rupture of the right shoulder, non-traumatic and a status post right reverse total arthroplasty. The Part D plan denied the request because it 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. The medical records show the doctor prescribed Diclofenac Epolamine patch for your condition. 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 the Diclofenac Epolamine because it was not prescribed for a medically accepted indication.