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

At issue is Stelara 90 milligram/milliliter injection prescribed for the enrollees condition. 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.Stelara 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 reimbursement for Folic Acid 1 milligram tablets. The request was denied because this drug is not covered by your plan without prior authorization. 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. You stated that you paid $44.12, cash, in August 2020 for folic acid tablets. Drugs prescribed that are available over the counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.We determined that the plan is not required to cover Folic Acid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Humalog Kwikpen 200 unit/milliliter pen injector prescribed for the enrollees condition. 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.Humalog Kwikpen is a biologic on Tier 3 of the plans formulary. There are no biologics of the same type to treat the enrollees condition on the lower cost sharing tiers. Therefore, this biologic 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 Leflunomide 20 milligram tablets prescribed daly for the enrollees condition. 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.Leflunomide is a generic drug on Tier 3 of the plans formulary. Your doctor submitted a supporting statement. The statement did not address why all alternative lower-tier medication on the plans formulary would not work for you. All generic drugs on lower tiers have not been tried. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clobetasol Propionate 0.05 percent solution. The Part D plan denied your request because the documentation did not support an off-formulary 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. We also researched Medicare systems and reviewed the enrollment data available. 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 the Clobetasol Propionate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Zolpidem Tartrate 5 milligram tablet for insomnia. 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 doctor provided a statement that Zolpidem Tartrate was prescribed to treat your insomnia. 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 Zolpidem Tartrate. 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

You requested Verzenio 150 milligram tablet prescribed for estrogen receptor positive advanced endometrial cancer. 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 records show you prescribed Verzenio 150 milligram tablet to treat the enrollees estrogen receptor positive advanced endometrial cancer. However, the Medicare approved compendia and Medicare approved journals do not support the use of this drug for this condition. An oncologist reviewed your appeal and determined that the plan is not required to cover Verzenio 150 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent patch prescribed for chronic neck pain and radiculopathy, lumbar region. The Part D plan denied coverage because medical necessity was not established. 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 record shows you were prescribed the Lidocaine patch for chronic neck pain and radiculopathy, lumbar region. In review of the Medicare approved compendia, chronic neck pain and radiculopathy, lumbar region is not a medically accepted indication for Lidocaine patch, as prescribed. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Lidocaine patch at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Brilinta 90 milligram tablets prescribed for the enrollees condition. 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. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Brilinta is a brand name Tier 3 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

You requested Erlotinib Hydrochloride 150 milligram tablet prescribed for metastatic squamous cell carcinoma of the right orbit, epithelium growth factor receptor positive. 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 records show you prescribed Erlotinib Hydrochloride 150 milligram tablet to treat the enrollees metastatic squamous cell carcinoma of the right orbit, epithelium growth factor receptor positive. However, the Medicare approved compendia and Medicare approve journals do not support the use of this drug for this condition. An oncologist reviewed your appeal and determined that the plan is not required to cover Erlotinib Hydrochloride 150 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methadone Hydrochloride 10 milligram tablets prescribed for fibromyalgia, seronegative erosive rheumatoid arthritis and polyarthritis. The Part D plan denied your request for a quantity limit 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 determined that the plan is not required to cover Methadone Hydrochloride 10 milligram tablets. Your prescriber did not provide the maximum daily opioid dose needed to manage your pain. The Medicare approved compendia does not support the excess dosage ordered. Therefore, the plan is not required to cover the requested quantity of Methadone Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Ubrelvy 100 milligram tablets prescribed for chronic migraines. 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.This drug is being 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gamunex-C 10 grams/100 milliliter intravenous injection prescribed for leucine-rich glioma inactivated 1 autoimmune encephalitis. 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 indicates your doctor prescribed Gamunex-C for leucine-rich glioma inactivated 1 autoimmune encephalitis. The Medicare approved compendia do not support the use of this biologic for your condition. As it cannot be determined that the biologic was 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Meformin ER 500 milligram osmotic tablet prescribed for type 2 diabetes mellitus. The Part D plan denied your request because the documentation did not support an off-formulary 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. 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 Meformin ER osmotic tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Tegretol XR 200 milligram tablets prescribed in the management of localization related epilepsy with a history of status epilepticus. 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. Tegretol XR 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

You requested Sildenafil Citrate 20 milligram tablets prescribed for pulmonary hypertension, World Health Organization group II. 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 records show you prescribed Sildenafil Citrate 20 milligram tablets to treat the enrollees pulmonary hypertension, World Health Organization group II. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil Citrate 20 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Hyoscyamine Sulfate 0.125 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request because the drug has not been approved by the Food and Drug Administration for the treatment of any condition. 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 determined that the plan is not required to cover Hyoscyamine Sulfate because the drug has not been approved by the Food and Drug Administration for the treatment of any condition. Drugs that have not been approved by the Food and Drug Administration 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 Cinacalcet Hydrochloride 60 milligram tablets for hyperparathyroidism. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the physician ordered the drug at issue for end-stage renal disease and hyperparathyroidism. According to Medicare rules, the requested drug is eligible for coverage under the end stage renal disease payment bundle. We determined that the plan is not required to cover the Cinacalcet Hydrochloride. Drugs which are eligible for Part B coverage are excluded from Part D coverage.We determined that the plan is not required to cover the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Adderall 10 milligram extended-release oral capsule prescribed daily for anxiety disorder unspecified and major depressive disorder, single episode. 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 your anxiety disorder, unspecified and major depressive disorder, single episode, unspecified. 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 Adderall extended-release.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ledipasvir-Sofosbuvir 90-400-milligram tablet to treat Hepatitis C. The Part D plan denied the 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 provided addressed the plans coverage criteria, and those criteria were not satisfied. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.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 Azathioprine 50 milligram tablets prescribed following a kidney transplant. The Part D Plan denied the 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 records show your doctor prescribed Azathioprine to prevent rejection following a kidney transplant. The Medicare approved compendia support the use of this drug for your condition. Based on the information provided, the drug is eligible for Part B coverage. Therefore, the drug is not eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is not required to cover Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dofetilide 260 microgram oral capsule prescribed daily for atrial fibrillation. 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.Dofetilide is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuzyra 150 milligram tablets prescribed daily for mycobacterial infection unspecified, mycobacterium abscesses, and other mycobacterial infections. 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 also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Nuzyra to treat your mycobacterial infection unspecified, mycobacterium abscesses, and other mycobacterial infections However, the Medicare approved compendia do not support the use of this drug for your conditions. 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 Nuzyra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lenvima 24 milligram capsule prescribed three time daily for malignant neoplasm of the major salivary gland. 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 Lenvima was prescribed to treat malignant neoplasm of the major salivary gland. At reconsideration, diagnosis is clarified as progressive unresectable salivaryadenocarcinoma (HER2-), [not indicated as Adenoid Cystic carcinoma]. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  A physician reviewed your appeal and determined that the plan is not required to Lenvima.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Eletriptan Hydrobromide 40 milligram tablets prescribed for migraine, unspecified, not intractable, without status migrainosus 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.Eletriptan Hydrobromide is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan would likely not be as effective as the requested drug for this condition, 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 Ozempic 0.25 milligrams/0.5 milligram Dose Pen prescribed as directed for diabetes mellitus. 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. We also researched Medicare systems and reviewed the enrollment data available. Ozempic 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.