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

At issue is Mometasone furoate 50 microgram nasal spray prescribed for allergic rhinitis. You requested that the plan provide a tiering exception. 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. Mometasone furoate is a generic drug on Tier 2 of the plans formulary. The doctor submitted a supporting statement, which said the enrollee could try a drug listed on Tier 1 of the plans formulary. However, the enrollee stated that they did not want to try that drug. The documentation from the physician does not support that alternative drugs would not work for this enrollee. 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 Lyrica CR 330 milligram capsules prescribed three time daily for chronic pain. You asked the Part D plan to provide a tier change 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 records show Lyrica CR is being prescribed for chronic pain. The Medicare approved compendia support the use of the requested drug for your condition. However, Lyrica CR is a brand name drug that is not on your plan's formulary. Your plan does not allow you to receive drugs not on the formulary at a lower cost share.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 requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Venclexta 100 milligrams tablets prescribed for acute myeloid leukemia. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The documentation submitted includes flow cytometry results, which confirm the enrollees diagnosis of acute myeloid leukemia on February 3, 2021. The Medicare approved compendia do support the use of this drug for the enrollee's condition. However, the plan requires that prior authorization criteria be addressed in a statement and supported in medical records. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Venclexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trokendi XR 100 milligrams prescribed for other migraine, not intractable, without status migrainosus. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. Your physician indicates you have tried beta blockers, Topamax, tricyclic antidepressants, triptans, and non-steroidal anti-inflammatory drugs. The documentation indicates the physician had prescribed Trokendi XR to treat your migraines. The Medicare approved compendia support the use of the requested drug for your condition.However, the records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Trokendi XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 620 microgram per 2.48-milliliter injection pen to treat the diagnosis of displaced fracture of lateral malleolus of left fibula. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read 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 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 your condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Revlimid 20 milligrams prescribed for multiple myeloma. The Part D plan denied your request for a tiering exception because the requested drug is in the highest specialty tier and the plan does not allow drugs in this tier at a lower cost-share. 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. Revlimid is a brand drug on Tier 5 of the plans formulary. Brand Revlimid is on the specialty tier of the plans formulary. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Revlimid at a lower cost-share.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluticasone Propionate Suspension 50 micrograms per actuation breath activated, 48 grams per 30 days, to treat chronic sinusitis. 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 plan limits the amount of Fluticasone Propionate Suspension micrograms per actuation breath activated to 16 grams per 30 days. Medical records from December 16, 2020 were provided which document that the prescriber is ordering Fluticasone nasal spray, one spray twice a day. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported.  Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested PreserVision AREDS 2 prescribed for age-related macular degeneration of both eyes. The Part D plan denied your request because the drug at issue was an over-the-counter 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 information submitted at the reconsideration level.We determined that the plan is not required to cover the drug at issue because it is an over-the-counter drug that does not require a prescription. Nonprescription or over-the-counter drugs 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

At issue is Oxycodone/Acetaminophen 10-325 milligrams, quantity of 100 for 30 days to treat chronic pain.  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 plan denied the appeal stating safety concerns.  In the Reconsideration appeal the prescriber addressed the safety concerns.  The provided documentation satisfies the plans coverage criteria.  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 Dexilant DR 60 milligram capsules prescribed for gastroesophageal reflux disease The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. We received 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.Dexilant 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vascepa 1 gram capsules prescribed as directed for hypertriglyceridemia. 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 prescriber statement shows the doctor prescribed Vascepa to treat hypertriglyceridemia. The prescriber statement indicates you do not have severe hypertriglyceridemia, diabetes mellitus, or established cardiovascular disease. 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 Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 micrograms prescribed as directed for chronic obstructive pulmonary disease. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an auto-forwarded 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 that your doctor prescribed Anoro Ellipta to treat your chronic obstructive pulmonary disease. The Medicare approved compendium supports the use of this drug to treat your condition. However, 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 Anoro Ellipta because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligrams auto-injector prescribed for atherosclerosis of the aorta. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records include a statement from the physician that Repatha was ordered for treatment of atherosclerosis of the aorta. However, the statement does not show why the enrollee cannot take other drugs listed on the Plans formulary for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Repatha. The enrollee has not tried all other alternatives listed within the Plans formulary to treat the condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligrams taken twice a day prescribed for hepatic encephalopathy. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. 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. Xifaxan is a brand drug on Tier 5, also known as the Specialty Tier, of the plans formulary. If a plan maintains a Specialty Tier, the plan may design its exception process so that drugs placed in the Specialty Tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the Specialty Tier from the tiering exception process. Therefore, this drug is not eligible for a tiering exception.This drug is being provided by your plan at the cost sharing level of the Specialty Tier. Specialty Tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kesimpta 20 milligram/0.4 milliliter pen prescribed for multiple sclerosis. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. The documentation indicates the physician had prescribed Kesimpta to treat your multiple sclerosis. The Medicare approved compendia support the use of the requested drug for your condition.However, the records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Kesimpta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram tablets for failure to thrive. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates Dronabinol was prescribed for failure to thrive. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xyrem, 500 milligrams/milliliter solution prescribed at bedtime for cataplexy and narcolepsy. The Part D plan denied coverage because the information received from your physician did not confirm that you had tried two central nervous system stimulants and confirmation of narcolepsy via a multiple sleep latency test. 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. Your medical records show that your doctor prescribed Xyrem to treat your cataplexy and narcolepsy. The Medicare approved compendium supports the use of this drug for your condition. However, your plan requires medical documentation (medical records) confirming that certain conditions have been met prior to the approval of this drug. The documentation provided does not show that you have satisfied the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 10 milligrams prescribed as directed for nausea related to an appendectomy. 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 Dronabinol 10 milligrams to treat your nausea related to an appendectomy. 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 Dronabinol 10 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Butalbital-Acetaminophen-Caffeine, 50-325-40 milligram tablets prescribed for headaches. The Part D Plan denied your request for a tiering exception because there were no lower tier alternatives of the same type on the plans formulary. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Butalbital-Acetaminophen-Caffeine at a lower cost tierButalbital-Acetaminophen-Caffeine 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. There must be a drug of the same type on a lower tier of the plans formulary for a tiering exception to be granted. Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligram tablets prescribed as directed for polymyositis and nonspecific interstitial pneumonia. 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 medical records show the doctor prescribed Mycophenolate Mofetil to treat polymyositis and nonspecific interstitial pneumonia. However, the Medicare approved compendia do not support the use of the drug for these conditions. A physician reviewed your appeal and determined that the plan is not required to cover the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Motegrity 2 milligram tablets prescribed for constipation due to irritable bowel syndrome. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed the drug for constipation due to irritable bowel syndrome. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gralise 600 milligrams prescribed daily for polyneuropathy in other diseases classified elsewhere and other idiopathic peripheral autonomic neuropathy. 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 Gralise 600 milligrams daily to treat your polyneuropathy in other diseases classified elsewhere and other idiopathic peripheral autonomic neuropathy. 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 Gralise 600 milligrams because it was not prescribed for a medically accepted indication.