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

At issue is Eliquis 5 milligrams prescribed twice daily for atrial fibrillation. The Part D plan denied your request for a tiering 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. Eliquis 5 milligrams 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 cover Eliquis 5 milligrams because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Multaq 400 milligrams prescribed twice daily to maintain normal sinus rhythm for an enrollee with persistent atrial fibrillation. The Part D plan denied your request for a tiering exception because the drug is not on the plans formulary. 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. Multaq is a brand drug that is not on the plans formulary. An enrollee may not request a tiering exception for a non-formulary prescription drug. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Multaq at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Topiramate 100 milligrams prescribed as directed for central stenosis of spinal canal. The Part D plan denied your request because it does not meet the criteria of 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 information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Topiramate 100 milligrams to treat your central stenosis of spinal canal. 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 Topiramate 100 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pristiq 100 milligrams prescribed to treat the diagnosis of depression. The Part D Plan denied the request stating that the tiering exception could not be provided at a lower cost share (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.The medical records show the requested drug to treat the enrollees condition is a non-formulary drug that was approved for coverage by the plan as a formulary exception effective January 1, 2021, through December 31, 2021. We have determined the requested drug is not eligible for a tiering exception since it is a non-formulary drug.A physician reviewed your appeal and determined that the requested drug is not eligible fora tiering exception..
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate HFA 90 micrograms prescribed  for chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception because there were no brand 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 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. Albuterol Sulfate is a generic drug on Tier 3 of the Plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.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: Favorable

At issue is Ofev 100 milligrams prescribed for the enrollees idiopathic pulmonary fibrosis. 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 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 enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee has idiopathic pulmonary fibrosis and a forced vital capacity greater than 40 percent of the predicted value.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin Tab 10 milligrams to treat an unknown diagnosis. 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 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. No medical records were received to address coverage criteria. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxsoralen UL 10 milligram capsule prescribed for t-cell lymphoma. The Part D plan denied your request to cover this drug at a lower tier cost. The plan indicated this is an approved non-formulary drug and cannot be provided at a lower tier cost. 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 Oxsoralen UL was prescribed; however, Oxsoralen UL is a non-formulary approved drug and is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the Oxsoralen UL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carbamazepine 200 milligrams tablet prescribed for seizures. 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 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 the enrollee was prescribed Carbamazepine to treat seizures. The following citation was referenced in a Medicare approved compendium, and supports the use of the requested drug for the enrollees condition. Carbamazepine is a generic drug on Tier 3 of the plans formulary. The prescriber statement indicates that the enrollee has tried and failed on Tegretol and Carbidopa-Levodopa. However, the plans formulary includes other lower tier generic alternatives of the same type to treat the enrollees condition. 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 Mycophenolate Mofetil 250 milligram capsules prescribed twice daily for prophylaxis of lung transplant rejection. The Part D plan denied your request because the medication is 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. The records show you prescribed Mycophenolate Mofetil to the enrollee status-post lung transplantation. 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humulin R 500 units/milligram kwikpen prescribed for type 2 diabetes mellitus. The Part D Plan denied your request for a lower-cost tiering exception because the medication is included in the plans specialty 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. Humulin R is listed on your plans formulary as Tier 5, which is the tier for specialty drugs. The plan does not grant tiering exceptions for specialty drugs. Therefore, this drug is not eligible for coverage at a lower-cost tier.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 Cinacalcet HCL 30 milligrams tablet for end stage renal disease on dialysis. 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 received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug would be eligible for coverage under Part B under Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone ER 60 milligrams prescribed twice a day for chronic lumbar radiculopathy. The Part D plan denied your request because the documentation did not support an off-formulary exception since not all preferred drugs were previously tried. We received an expedited 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 physician submitted a supporting statement. The prescriber statement shows the physician had prescribed Oxycodone ER to treat chronic lumbar radiculopathy. However, the records do not show why preferred alternatives on the plans formulary for the same condition have not been tried. Specifically, the documentation does not show that the enrollee has tried other formulary alternatives, or why the enrollee cannot take them.A physician reviewed your appeal and determined that the plan is not required to grant a non-formulary exception for the Oxycodone ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuplazid 24 milligram tablet prescribed daily for Parkinsons disease dementia. The Part D plan denied your request for a tiering exception because there are no lower tier alternatives of the same type for 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. Nuplazid is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception. There is no brand drug on a lower eligible tier of the same type that is used to treat your condition. Therefore, your plan is not required to offer you a lower cost share.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cosentyx 150 milligram/milliliter injection pens  prescribed for plaque psoriasis. You requested that the plan provide an off-formulary exception for this drug. The plan did not make a decision within the required timeframe. We received an auto-forwarded reconsideration request from the plan.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation does not show why the enrollee cannot take drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Cosentyx.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate hydrochloride 10 milligram tablets prescribed daily for fatigue related to multiple sclerosis and demyelinating disease. 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. The documentation shows the doctor prescribed Methylphenidate hydrochloride to treat fatigue related to multiple sclerosis and demyelinating disease. 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 Methylphenidate hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Corlanor 5 milligrams prescribed daily for postural orthostatic tachycardia syndrome. 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 Corlanor 5 milligrams daily to treat your postural orthostatic tachycardia syndrome. 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 Corlanor 5 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Dexilant 60 milligram DR capsules twice per day for gastro-esophageal reflux disease. The Part D plan denied the 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. Dexilant 60 milligrams is a brand name drug on Tier 4 of the plans formulary. There are no brand name drugs of the same type on the lower tiers of the plan's 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

Your request for a reconsideration was initially dismissed due to non-timely filing. However, you have submitted documentation supporting a good cause for the late filling. Therefore, a reconsideration request will be performed.At issue is Nexlizet, 180/10 milligram tablets prescribed for hyperlipidemia. The Part D plan denied your request because hyperlipidemia is not a Food and Drug Administration-approved diagnosis for the use of this medication. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Nexlizet because hyperlipidemia is not medically accepted indication to use this drug.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. Therefore the requested drug is not being prescribed for a medically accepted indications as defined by Medicare law.  As such, the requested drug does not meet the definition of a Medicare Part D drug and is therefore not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sodium Chloride 0.9% vial prescribed for conjunctival squamous cell carcinoma. 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 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.One or more drugs within the compound medication you requested are covered under Medicare Part B. The part of the compound that is at issue may also be eligible for coverage under Part B. We have determined that the plan is not required to cover Sodium Chloride as it is not a Part D eligible drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dexilant 60 milligrams  prescribed daily for gastroesophageal reflux disease with esophagitis. 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. The records do not adequately show why you cannot take other drugs on the plans formulary for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Dexilant.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sterile Water Solution for injection. The Part D plan denied your request because Medicare Part D does not cover Sterile Water solution. 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 also researched Medicare systems and reviewed the enrollment data available. The records support that the Sterile Water Solution is being prescribed to be added to a total parenteral nutrition compound solution for the enrollee, which is to be the enrollees sole nutrition source due to irreversible intestinal failure. The documentation shows that the other components of the total parenteral nutrition compound, Travasol 10% Solution Injection, Dextrose 70% Injection, and Smoflipid 20%, have been covered. However, Sterile Water Solution is excluded from Medicare Part D coverage, even when it is part of compound. Only Part D eligible drug product components are covered within a compound. The plan does not offer supplemental (additional) coverage for this drug. 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 Lidocaine 5 percent patch prescribed as needed for myalgia and pain in leg. The Part D plan denied your request because it does not meet the criteria of 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 information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Lidocaine 5 percent patch as needed to treat your myalgia and pain in leg. 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 Lidocaine 5 percent patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Viberzi, 100 milligram tablets prescribed for irritable bowel syndrome with diarrhea. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Viberzi as an off-formulary exception.Your doctor submitted a supporting statement stating that Viberzi was prescribed to treat your irritable bowel syndrome with diarrhea. The Medicare approved compendia support the use of the requested drug for your condition. However, the submitted documentation does not address why the drugs listed in your Part D plans formulary to treat your condition have not been tried, or are contraindicated. Therefore, the plan will not cover the Viberzi as an off-formulary exception.