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

You requested Temazepam 30 milligram capsules prescribed daily for restless leg syndrome and hypersomnia. The Part D plan denied your request 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 information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Temazepam for restless leg syndrome and hypersomnia. You have been on this medication since 2019. The Medicare approved compendia do not support the use of this drug for your condition. The drug is approved for the treatment of short-term (seven to 10 days) insomnia. 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

At issue is Repatha 140 milligram/milliliter pen injector prescribed for the enrollees pure hypercholesterolemia. 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 documentation supports the drug was prescribed for the enrollees diagnosis of pure hypercholesterolemia and has a history of ST elevation myocardial infarction, coronary arteriosclerosis, essential hypertension, and atherosclerosis of native coronary artery of native heart without angina pectoris. However, the enrollee does not satisfy the plan's prior authorization 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

You requested Pramipexole ER 4.5 milligram tablets prescribed daily for restless legs syndrome. 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 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 Pramipexole ER for restless legs syndrome. The Medicare approved compendia do not support the use of this drug for your condition. The immediate release formula is indicated for the treatment of restless legs syndrome. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed. A tiering request cannot be granted for a drug that is not medically indicated.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 Mesalamine 400 milligram tablet prescribed two tablets three times daily for ulcerative colitis. 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 show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Mesalamine 400 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Frova 2.5 milligram tablet prescribed for migraine headaches. The Part D plan approved your off-formulary request but 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.Frova 2.5 milligram tablet is a non-formulary drug. 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 Guanfacine HCl 1 milligram tablets prescribed for bipolar disorder and attention deficit hyperactivity disorder. 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 Guanfacine HCl for bipolar disorder and attention deficit hyperactivity disorder. 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 Privigen 5 grams/50 milliliters for intravenous infusion prescribed as directed for autoimmune necrotizing myopathy associated with positive anti-HMGCR antibody. 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 Privigen for autoimmune necrotizing myopathy associated with positive anti-HMGCR antibody. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Privigen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Sodium Delayed Release 360 milligram tablet to treat the enrollees condition. The Part D plan did not provide a timely redetermination decision. 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. We also researched Medicare systems and reviewed the enrollment data available.The medical records show the requested drug is being prescribed to treat the enrollees condition. The enrollees medical history includes a kidney transplant on June 26, 2008. According to Medicare, the enrollee was under Medicare Part A coverage at the time of the transplant. Based on the information provided, we have determined the requested drug is not eligible for Medicare Part D coverage, but would be covered under Part B.A physician reviewed your appeal and determined that the requested drug is not eligible for Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bupropion HCl 100 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the prescriber did not provide a diagnosis. 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 record contains a progress note from your doctor that indicates you have a diagnosis of depression, which is a medically accepted indication for the drug at issue. Bupropion HCl is a generic drug on Tier 3 of the plans formulary. A supporting statement from your doctor was requested to address if all alternative generic medications on a lower tier were tried. However, your doctor did not submit the statement to 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 Gralise 600 milligram tablets prescribed 4 times daily for hereditary and idiopathic neuropathy. 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 Gralise for hereditary and idiopathic neuropathy. 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

At issue is Dexilant 60 milligram capsules prescribed for 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.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 Cresemba 186 milligram capsule prescribed twice daily for fungal infection prophylaxis. 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 Cresemba for fungal infection prophylaxis. 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 Nubeqa 300 milligram tablets prescribed for metastatic castration-sensitive prostate cancer. 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 Nubeqa for metastatic castration-sensitive prostate cancer. The Medicare approved compendia do not support the use of this drug for your condition. There are no citations in the compendia to support the use of the 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

At issue is Livalo 2 milligram tablets prescribed for hyperlipidemia. 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 supporting statement stated the enrollee had an intolerance to statins. 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 Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acitretin 10 milligram capsules prescribed as directed for psoriasis. The Part D plan denied coverage because the prior authorization criteria were not met. 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.We asked your prescriber to send us information regarding your condition. We did not receive the documentation requested.The documentation available for review does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Acitretin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Leflunomide 20 milligram tablets prescribed as directed for BK virus associated nephropathy. The Part D plan denied your request for a tiering exception 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 Leflunomide for BK virus associated nephropathy for an enrollee after a renal transplant. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Leflunomide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz 5 milligram tablets prescribed for oral lichen planus. 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 Xeljanz for oral lichen planus. 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

At issue is Pennsaid 2% pump prescribed for osteoarthritis of the unilateral knee. 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 asked the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The medical records show Pennsaid was prescribed to treat osteoarthritis of the unilateral knee. The Medicare approved compendia do support the use of this drug for this condition. The plan requires prior authorization criteria be met before they will cover the requested drug. The documentation provided does not adequately 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 Pennsaid 2% pump.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 112 microgram tablets prescribed daily for the enrollees condition. 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 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.Synthroid 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligrams/milliliter injection prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand biologics on a lower cost-sharing 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.Repatha Sureclick is a brand biologic on Tier 3 of the plans formulary. There are no brand biologics of the same type 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 Myrbetriq ER 50 milligram tablet prescribed daily for overactive bladder with urgency and urge incontinence. The Part D Plan denied your request for a tiering exception because there were no brand alternatives on 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. Myrbetriq ER 50 milligram tablet 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

At issue is Entresto 97 milligram tablets prescribed for other cardiomyopathies. 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 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. Entresto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat your condition on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 5 milligram capsules prescribed twice daily for nausea/anorexia associated with anxiety disorder. 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 Dronabinol for nausea/anorexia associated with anxiety disorder. 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 a tier exception for Januvia 100 milligram tablets prescribed for diabetes. The Part D plan denied your request for a tiering exception because Januvia 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 Januvia 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.