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

At issue is Doxycycline DR 40 milligram capsule prescribed for rosacea. 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 asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Doxycycline DR 40 milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100-62.5-25 micrograms aerosol powder blister actuation per inhalation. 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.Trelegy Ellipta 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 Belbuca 150 microgram film prescribed for chronic pain syndrome. 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Belbuca.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Butalbital/Acetaminophen/Caffeine/Codeine Phosphate 50-325-30 milligram capsules (240 capsules per 30 days) prescribed for migraine headaches. 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. Butalbital/Acetaminophen/Caffeine/Codeine Phosphate has been 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. Also note that the prescriber has requested 240 capsules per 30 days.  DrugDex, a Medicare approved compendia, states, ' Maximum dosage: 6 capsules/day [2]' 2. Product Information: Butalbital, Acetaminophen, Caffeine, Codeine Phosphate oral capsules, butalbital, acetaminophen, caffeine, codeine phosphate oral capsules. Actavis Pharma, Inc. (per FDA), Parsippany, NJ, 2019.Finally, the label states: 'Beers criteria: Use caution or avoid use as potentially inappropriate in older adults [1].  1. American Geriatrics Society Beers Criteria Update Expert Panel: American Geriatrics Society 2019 updated AGS Beers Criteria(R) for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2019; 67(4):674-694.PubMed Abstract: http://www.ncbi.nlm.nih.gov/...PubMed Article: http://www.ncbi.nlm.nih.gov/...
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Victoza solution pen-injector18 milligrams/3 milliliters. 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.Victoza 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 Eliquis 5 milligram tablet prescribed twice daily for anticoagulation in chronic atrial fibrillation. 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 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.Eliquis 5 milligram tablet 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 Calcitriol 0.25 microgram capsules prescribed for chronic kidney disease. 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. Your prescriber indicated that Calcitriol is prescribed for chronic kidney disease and you are no longer on dialysis. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Calcitriol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10-milligram tablet to treat insomnia. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Granisetron Hydrochloride 1 milligram tablet prescribed for nausea related to gastroparesis. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Granisetron Hydrochloride to treat your nausea related to gastroparesis. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Granisetron Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Progesterone 100 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 Progesterone has been prescribed for the treatment of progesterone deficiency. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of 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 Progesterone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mesalamine Extended Release 0.375-gram tablet to treat ulcerative colitis, unspecified without complication. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 prescriber has not provided patient specific clinical rationale, supported by medical records, as to 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. Therefore, an exception to the plans formulary coverage criteria is not supported.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluorouracil 5% cream prescribed daily for the enrollees condition. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Fluorouracil is a generic drug on Tier 4 of the plans formulary. The documentation on hand does not address why all alternative lower-tier medication on the plans formulary would not work for you. All generic drugs on lower tiers have not been tried. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Zolpidem Tartrate 10 milligram tablets prescribed daily for insomnia. The Part D plan denied coverage.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 on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies 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

At issue is Nourianz 20 milligram tablet prescribed as an adjunct to Sinemet for an enrollee with off episodes associated with Parkinsons disease. 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Nourianz 20 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mavyret 100-40 milligram tablets to treat chronic hepatitis C, genotype 1a, in a treatment naive enrollee without cirrhosis.   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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hysingla ER 20 milligram tablet prescribed for chronic low back pain. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Hysingla ER 20 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrocodone Acetaminophen 7.5-325 milligram tablets prescribed for unknown diagnosis. 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. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, documentation was provided showing that this claim was covered by the plan at the time of purchase, and the amount you paid was either applied to your deductible or a copay/coinsurance. We determined that the plan is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 10 milligram tablet prescribed three times daily for muscle spasms due to chronic back pain. 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 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 Cyclobenzaprine Hydrochloride was prescribed to treat the enrollees chronic back pain and muscle spasms. However, the Medicare approved compendia do not support the use of this drug for this chronic condition. A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Zioptan 0.0015% ophthalmic solution prescribed for bilateral open angle glaucoma. 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.Zioptan is not included in the plans formulary. The prescriber has noted that the enrollee requires a preservative-free eye drop. Travoprost mentioned in the coverage determination contains preservative. The formulary includes other preservative-free glaucoma eye drops. The prescriber has addressed why these alternative medications would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is supported.Our physician reviewer's opinion is that formulary exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sterile Water for Irrigation. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. Sterile Water for Irrigation does not satisfy the definition of a Part D drug. This item is being used to help ensure durable medical equipment is usable. This is excluded from Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Sterile Water for Irrigation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 3 milligram capsule prescribed 12 milligrams daily for noninfectious gastroenteritis and colitis. 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 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 doctor prescribed Budesonide capsules to treat the enrollees noninfectious gastroenteritis and Ipilimumab-induced colitis. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed the appeal and determined that the plan is not required to cover Budesonide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ledipasvir-Sofosbuvir 90-400 milligram tablet prescribed for hepatitis C, chronic, unknown genotype, treatment-naive, with compensated cirrhosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The records show you prescribed Ledipasvir-Sofosbuvir 90-400 milligram tablet to treat the enrollees hepatitis C, chronic, unknown genotype, treatment-naive, with compensated cirrhosis. 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 Ledipasvir-Sofosbuvir 90-400 tablet. Therefore, the Part D plan cannot consider a formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch for a  left hip fracture. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Lidocaine 5% patch for a left hip fracture. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine/Dextroamphetamine 20 milligram capsule prescribed for hypersomnia. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.The documentation shows your doctor prescribed Amphetamine/Dextroamphetamine for hypersomnia. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Amphetamine/Dextroamphetamine.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Erythrocin Filmtab 500 milligram prescribed for a pleural effusion, for which culture results indicated bacteria sensitive to erythromycin. The Part D plan found the drug to be medically necessary for your condition, granted a formulary exception, but a drug-drug interaction was identified with another drug you were using, hydroxychloroquine, and 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. Your prescriber and pharmacist evaluated the drug-drug interaction and indicate the drug interaction has a minor risk severity for QT prolongation. They provided a plan to mitigate any risk.  Therefore, based on the plans approval of the drug, a formulary exception is granted.A physician reviewed your appeal and determined that the plan is required to cover Erythrocin Filmtab.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promacta 50 milligram tablet prescribed two per day for chronic idiopathic thrombocytopenic purpura. 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 the 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 medical records show the doctor prescribed Promacta prior to surgery due to the enrollees chronic diopathic thrombocytopenic purpura. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Promacta. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acitretin 25 milligram tablets prescribed to treat Dariers disease in an enrollee with hyperlipidemia.   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 documentation does not satisfy the plans coverage criteria. The prescriber states that the enrollee has chronic abnormally elevated blood lipid values.  The plans coverage criteria are not satisfied by the provided medical records.  The medical records substantiate the diagnoses of hyperlipidemia and Dariers disease. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.