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

You requested coverage for Promethazine 25 milligram tablets prescribed daily for nausea. 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 Promethazine for nausea. In review of the Medicare approved compendium, Promethazine is only indicated for nausea and vomiting, prevention and control prior to surgery or postoperatively. Therefore, it does not meet the definition of a Part D drug for your  condition. The plan is not required to cover the Promethazine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Edecrin 25 milligram tablet twice daily to treat the enrollees condition. The Part D plan did not make a decision.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 Toujeo Solostar 300 units/ milliliter pen injector prescribed as directed for type 2 diabetes mellitus without complications. 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. 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 Toujeo Solostar. A physician reviewed your appeal and determined that the plan is not required to cover the Toujeo Solostar.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Exforge 10 milligram-320 milligram tablets prescribed as directed for chronic diastolic (congestive) heart failure and essential hypertension. 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.  The requested drug is being provided by your plan under a formulary exception. Exforge 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 non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Lumigan 0.01% eye drops prescribed for primary open angle glaucoma of both eyes. The Part D plan forwarded the case to us for review.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 submitted prescriber statement indicates that the enrollee requires a 10 milliliter bottle of Lumigan eye drops for a 90-day supply. However, this exceeds the plans quantity limit restriction for Lumigan eyes drops, which is a maximum of 2.5 milliliters per 25 days. The prescriber has not explained the necessity for exceeding the plans quantity limit restriction. The plans quantity limit criteria have not been satisfied for the continued request for a 90-day supply. If the prescriber were to order 2.5 milliliters for a 25-day supply, the quantity limit would be met.A physician reviewed your appeal and determined that the plan is not required to cover the Lumigan eye drops above the quantity limit of 2.5 millilters per claim, which is a 25-day period.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Bystolic 5 milligram tablets prescribed to treat the diagnosis of unspecified diastolic heart failure. The Part D plan denied the request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read 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.Bystolic is a brand drug on Tier 3 of the plans formulary. There are no brand names of the same type on the lower cost-sharing levels. In addition, the prescriber has not indicated why all alternatives required by the plan have not been tried and would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. 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

At issue is coverage for Butalbital-Aspirin-Caffeine-Codeine 50-325-40-30 milligram capsules. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Butalbital-Aspirin-Caffeine-Codeine has been prescribed for the treatment of migraine with aura, not intractable, without status migrainosus.  However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Butalbital-Aspirin-Caffeine-Codeine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Coreg CR 80 milligram extended-release capsule for the enrollees condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.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 Dextroamphetamine-Amphetamine 20 milligram capsules prescribed daily for multiple sclerosis related fatigue. 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 Dextroamphetamine-Amphetamine for multiple sclerosis related fatigue. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that the drug 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 drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Farxiga 10 milligram tablet to treat your diabetes. 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.Farxiga is a brand drug on Tier 4 of the plans formulary. The prescriber has not indicated if all brand drug 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

You requested a lower cost tiering exception for Eliquis 5 milligram tablets prescribed to treat deep vein thrombosis. 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. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition 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. A physician reviewed your appeal and determined that the plan is not required to cover the Eliquis at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed twice daily for skeletal muscle spasms due to chronic back pain. 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 c Hydrochloride for skeletal muscle spasms due to chronic back pain. However, the Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that the drug 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 drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cortifoam 10% foam prescribed as directed for hemorrhoids and rectal pain. 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.No medical records were provided by the prescriber. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Cortifoam foam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eplerenone 50 milligram tablet prescribed as directed to treat essential hypertension and chronic systolic heart failure. 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 records do not show why the enrollee cannot take other drugs, such as Amiloride on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover the Eplerenone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested NP Thyroid 90 milligram tablets prescribed to treat hypothyroidism. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is 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.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 Lidocaine 5 percent patches prescribed daily for chronic pain and cervical radiculopathy. 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. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine 5 percent patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Loteprednol Etabonate 0.5% suspension prescribed to treat the diagnosis of chronic uveitis. 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.Loteprednol Etabonate 0.5% is not on the plans formulary. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees 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 Loteprednol Etabonate 0.5% suspension.
Appeal type: Prescription Drug
Decision: Favorable

You requested Xopenex HFA prescribed to treat asthma. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The plan requires prior authorization/step therapy requirements be met before covering this drug. The physician indicates the enrollee has tried Ventolin, and generic Albuterol, but was intolerant and it was ineffective. The step therapy requirements were met. Medical records were submitted to substantiate statements.A physician reviewed your appeal and determined that the plan is required to cover Xopenex.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cayston 75 milligrams nebulized solution prescribed three times daily for bronchiectasis and chronic Pseudomonas aeruginosa pulmonary infection. 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. The use of the requested drug to treat the provided diagnoses 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 the enrollees condition. 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 Cayston.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Megestrol Acetate 400 milligrams/10 milliliters oral suspension prescribed daily for abnormal weight loss. 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. We also researched Medicare systems and reviewed the enrollment data available. 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 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 Megestrol Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

Oxycodone-Acetaminophen 7.5-325 milligram tablets was requested to treat the enrollees condition. The Part D plan denied your request. 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.A request was submitted to the prescriber to provide a diagnosis and supporting medical records.  A reply from the prescriber was not received. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug. 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Levemir Flex touch 100-milliliter insulin pen prescribed for diabetes. The Part D plan denied your request for a tiering exception because Levemir Flex touch is a brand name Tier 3 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 plan shows Levemir Flex touch 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 Otezla 10 milligram tablets prescribed as directed for erythema multiforme. 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. The use of the requested drug to treat the provided diagnoses 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 the enrollees condition. 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 Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Theophylline ER 300 milligram tablets. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Theophylline ER has been prescribed for the treatment of vasovagal syncope. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Theophylline ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Trulicity 0.75 milligram per 0.5-milliliter insulin pen prescribed for diabetes. The Part D plan denied your request for a tiering exception because Trulicity is a brand name Tier 3 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 plan shows Trulicity is a brand name Tier 3 drug. There are no brand name drugs of the same typeon the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.  Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Effer-K 20 milliequivalents effervescent tablet prescribed for hypokalemia. The Part D plan denied your request because the requested drug is not considered a Part D covered 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. We determined that the plan is not required to cover Effer-K because it is not an approved Food and Drug Administration drug. A covered Part D drug must be approved by the Food and Drug Administration. 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.