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

You requested coverage for Dupixent subcutaneous solution prefilled syringe 300 milligrams per 2 milliliter prescribed daily for persistent mild asthma, allergic rhinitis, and atopic dermatitis. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. Your medical record shows you were prescribed Dupixent for persistent mild asthma, allergic rhinitis, and atopic dermatitis. You also have a history of nasal polyps.In review of the Medicare approved compendia, atopic dermatitis is a medically accepted indication for Dupixent when moderate to severe and not adequately controlled with topical prescription therapies or when those therapies are inadvisable. However, the documentation submitted does not support the coverage criteria required. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Dupixent at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Morphine Sulfate ER 15 milligrams to treat an unspecified 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 the appeal carefully. We reviewed all available documentation.The prescriber has not indicated that you have a medically accepted diagnosis or require the quantity and dose requested. Our Physician Reviewer's opinion is that the requested medication is not medically necessary.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Morphine Sulfate 15 milligrams to treat an unspecified 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 the appeal carefully. We reviewed all available documentation.The prescriber has not indicated that you have a medically accepted diagnosis or require the quantity and dose requested. Our Physician Reviewer's opinion is that the requested medication is not medically necessary.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trelegy Ellipta 100 microgram/62.5 microgram/25 microgram. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. Trelegy Ellipta is a brand drug covered at the cost-sharing tier.  There are no brand drugs of the same type on the lower tiers of the plans 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

At issue is Livalo 2 milligrams. The Part D plan denied your 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. There were no medical records submitted.The documentation provided is not sufficient to determine whether the medication requested is being prescribed for a medically accepted indication, in  order to be considered for Part D drug coverage.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 Armour Thyroid 180 milligram tablets. The Part D Plan denied your request for a tiering exception because there were no other similar 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. A physician reviewed your appeal and determined that the plan is not required to cover the Armour Thyroid at a lower cost tier.Armour Thyroid is a brand name drug on Tier 3 of the plans formulary. There are no brand name drugs of the same type on the lower cost sharing tiers. If there are no brand name drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. Therefore, a tiering exception cannot be granted for the Armour Thyroid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tysabri 20 milligrams/1 milliliter solution prescribed 300 milligrams monthly for multiple sclerosis. 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 reviewed your appeal carefully. We reviewed all documentation available. Your physician submitted a supporting statement. The supporting statement did not support all alternative formulary medications to treat your condition were tried and failed. A physician reviewed your appeal and determined that the plan is not required to cover Tysabri.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligram Sureclick to treat 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 appeal carefully. We reviewed all available documentation.The prescriber has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans 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 Adderall XR 30 milligrams prescribed for depression. The Part D plan denied your request. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician did not indicate formulary alternatives would be ineffective. 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 Adderall.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Budesonide to treat unknown diagnosis. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. Budesonide is a brand drug on Tier 3 of the plans formulary. The prescriber has not indicated that the enrollee has tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective for the enrollee as the requested drug.  Therefore, this drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide three milligram oral capsule to treat chronic graft versus host disease  - gastrointestinal tract.  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 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 use of the requested drug to treat the provided diagnosis is an off-label use.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 200 milligrams to treat multiple sclerosis related fatigue. The Part D plan denied the request. 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 regulations and Medicare approved compendia. 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 the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligrams prescribed for the enrollees plaque psoriasis. The plan did not make a decision within the required timeframe. The case was auto-forwarded by the plan.  The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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 plaque psoriasis. 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

At issue is Kesimpta prescribed for to treat the enrollees condition. The Part D plan denied your 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. There were no medical records submitted. The documentation is insufficient to determine what the enrollees diagnosis is and if the medication is medically indicated.A physician reviewed your appeal and determined that the plan is not required to cover Kesimpta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Brovana Nebulizer Solution prescribed for chronic obstructive pulmonary disease. 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 performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. We determined that the drug is eligible for Part B coverage. Therefore, the drug cannot be considered for payment under the Part D benefit.Your medical records show your doctor prescribed Brovana to treat your condition. However, the drug is administered through your nebulizer at home and therefore it is covered under Part B.A physician reviewed your appeal and determined that the plan is not required to cover Brovana.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for nisolodipine to treat hypertension. 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 appeal carefully. We reviewed all available documentation.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sirolimus,1 milligram tablets prescribed for anti-rejection following a liver transplant. 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 Sirolimus because anti-rejection for liver transplant is not a 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 indication 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 Corlanor 5 milligram tablets to treat tachycardia. 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 reviewed all documentation submitted.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 the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolic Acid 360 milligram DR tablets to treat an unknown diagnosis. 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 the appeal carefully. We reviewed all documentation available.It cannot be established that the requested drug is being used for a medically accepted indication based on no records available for review. Medical records were not received as requested. It therefore cannot be considered a Part D drug, and is not available for coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symbicort aerosol 160/4.5 micrograms/ACT prescribed to treaty the enrollees condition. The Part D plan denied your request for a tiering exception. 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. Symbicort aerosol 160/4.5 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 Symbicort aerosol 160/4.5 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 Dificid 200 milligrams to be given two times a day for clostridium difficile diarrhea. The Part D plan denied the drug because a recurrence after completing a full course of vancomycin is not considered failure of vancomycin. The plan requires prior approval before covering some 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.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Freestyle Diabetic Reader. The case was auto-forwarded by the plan. 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 Freestyle Diabetic Reader would be eligible for coverage under Medicare Part B rules. Therefore, the Medicare Part D Prescription Drug benefit is not required to cover the medical equipment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fetanyl 50 micrograms patch prescribed as directed for chronic back pain. 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. The records show you were prescribed Fetanyl to treat your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided do not show the plan's coverage criteria have been met. No medical records were received to substantiate that the plan's coverage criteria were satisfied.A physician reviewed your appeal and determined that the plan is not required to cover the Fetanyl.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue are Lidocaine 5% patches prescribed for vertebral compression fracture. The Part D plan denied your request because you did not have a covered 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. A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine patches because vertebral compression fracture is not a 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 indication 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 Pilocarpine Hydrochloride 5 milligram tablets prescribed twice daily for sicca syndrome or Sjogrens 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.Pilocarpine Hydrochloride is a generic drug on Tier 4 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 grant the tiering exception. There are no lower tiered generic drugs of the same type to treat your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyanocobalamin injection prescribed to treat vitamin B deficiency. 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.Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations are excluded from coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anucort HC 25 milligrams. 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.No medical records were provided by the prescriber. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the Anucort HC because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Mesalamine 4 gram enema to treat Crohns disease. 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.Mesalamine is a generic drug on Tier 4 of the plans formulary. There are no generic drugs of the same type on the lower tiers of the plans 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

At issue is Eliquis 5 milligrams prescribed for arial fibrillation. The Part D Plan denied the request because your pharmacy was out-of-network pharmacy and not covered by the Medicare Part D plan. 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.Medicare Part D does not cover drugs dispensed from an out-of-network pharmacy. The record shows that Eliquis was obtained from an out-of-network pharmacy. We determined that the plan is not required to reimburse you for the Eliquis. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit. In conclusion, the decision of the QIC is unfavorable.