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

At issue is a tiering exception request for Depakote ER (Divalproex Sodium) 500 milligrams prescribed for seizures. 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.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 Buprenorphine Hydrochloride 8 mg sl tablet to treat chronic pain.  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 Renflexis 100 milligram vial prescribed as intravenous infusion of every 8 weeks to treat the diagnosis of 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.The medical records show the requested drug is being prescribed to treat the enrollees condition. However, Renflexis is not on the plans formulary. In addition, 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 Avodart 0.5 milligrams prescribed as directed for an unknown diagnosis. The Part D plan denied coverage because the prior authorization criteria were not met. 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 prescriber was asked to state the diagnosis since the diagnosis was not contained within the appeal. The prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the Plans prior authorization criteria. A response from the prescriber was not received. Therefore, based upon the current record, 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 Avodart.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tymlos 3120 micrograms/1.56 milliliter injection pen prescribed for age-related osteoporosis without current pathological fracture. 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. Your medical records show your doctor prescribed Tymlos to treat age-related osteoporosis without current pathological fracture. Medicare approved compendia does support the use of this drug for your diagnosis. However, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We requested additional documentation from the prescriber but did not receive it.A physician reviewed your appeal and determined that the plan is not required to cover Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Hizentra 4 gram per 20 milliliter solution. The Part D plan denied the request stating that the medication was being prescribed for a non-medically accepted indication.  We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The documentation indicates that the Hizentra has been prescribed for nonfamilial hypogammaglobulinemia. Use of Hizentra for the enrollee's condition is a medically accepted indication supported by the Medicare approved compendia. However, review of the medical records supports the diagnosis of common variable immune deficiency; a diagnosis covered under Part B Medicare. Drugs eligible for coverage under Part B are not Part D drugs. 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 Hizentra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablet prescribed to treat your condition. 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. 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

You requested compounded Amitriptyline-Baclofen 2% cream prescribed for perineal paresthesia. The Part D plan denied your request to cover the requested compounded medication. 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. This drug is a compounded drug. Therefore, we reviewed each ingredient individually.  The ingredients of the requested drug are: Baclofen Powder, Amitriptyline Powder, and Preservative Free Cream compound.Preservative Free Cream is a non-prescription or over-the-counter (OTC) drug. Medicare Part D does not cover non-prescription drugs. Therefore, the Preservative Free Cream ingredient is not eligible for Part D coverage. Baclofen and Amitriptyline Powder are bulk powders. Bulk powders (i.e., Active Pharmaceutical Ingredients for compounding) do not satisfy the definition of a Part D drug and are not covered by Part D. Therefore, none of the ingredients of the requested drug are Part D drugs. Compounded medications that do not contain at least one ingredient that meets the definition of a Part D drug are excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Chantix 1 milligram tablets for smoking cessation. 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.Chantix is a brand drug on Tier 4 of the plans formulary. 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 a tiering exception request for Myrbetriq ER 50 milligram tablets for treatment of the enrollees condition. 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.Myrbetriq ER is a brand drug on Tier 3 of the plans formulary. 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

You requested Tadalafil 5 milligram oral tablet prescribed daily for post-prostatectomy. The Part D plan denied your request because the requested drug is not covered under Medicare Part D. 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 Tadalafil because it is being used to preserve erectile function following radical prostatectomy. Drugs prescribed for the treatment of sexual or erectile dysfunction 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: Unfavorable

At issue is a tiering exception request for Oxycontin 20 milligram CR prescribed for the treatment of the enrollees condition. 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.This drug is being provided by your 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 exceptionOur physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Fluorouracil 5% cream to prevent skin cancer. 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.Fluoruricil 5% cream is a generic drug on Tier 3 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 Dupixent 300 milligrams per 2 milliliters syringe to treat moderate to severe asthma. 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 record shows the requested drug was being prescribed to treat the provided diagnosis. 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 enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 Esomeprazole magnesium 40 milligrams prescribed as directed to treat gastric reflux and erosion of the esophagus. 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 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 record shows that your doctor prescribed Esomeprazole magnesium to treat your condition. There are no medical records to support 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 Esomeprazole magnesium because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Premarin 0.625 milligram/gram cream with applicator to treat atrophic vaginitis. 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.Premarin vaginal cream 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Linzess 145 microgram capsule prescribed as directed to treat the enrollees condition. 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.Linzess 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablets for treatment of the enrollees condition. 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.Eliquis is a brand drug on Tier 3 of the plans formulary. 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 Buprenorphine hydrochloride 8 milligram sublingual tablets to treat opioid dependence. The Part D plan denied the request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan would likely cause harm or not be as effective as the requested drug. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage. Our physician reviewer's opinion is that prior authorization criteria are not met and the plan is not required to cover Buprenorphine hydrochloride 8 milligram sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Trulicity (Dulaglutide) 1.5 milligram/0.5 milliliter pen injection solution prescribed daily for type 2 diabetes. The Part D plan denied your request for a tiering exception because Trulicity 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 record shows Trulicity is being prescribed for type 2 diabetes. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Trulicity 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine patch 5 percent prescribed for pleurodynia.  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 record shows you were prescribed Lidocaine patch for pleurodynia. In review of the Medicare approved compendia, pleurodynia is not a medically accepted indication for Lidocaine patch. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Lidocaine patch at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rasuvo 20 milligrams/0.4 milliliter subcutaneous injection prescribed weekly for rheumatoid arthritis without rheumatoid factor. 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 physician submitted a supporting statement. The documentation indicates the physician had prescribed Rasuvo to treat rheumatoid arthritis without rheumatoid factor. However, the records do not show why the enrollee cannot take other drugs on the plans formulary. The physician did not indicate all alternatives to treat the enrollee's 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 Rasuvo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% Ointment to treat osteoarthritis of an unspecified site.  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 prescriber provided a diagnosis of osteoarthritis of unspecified site.  The enrollee provided a diagnosis of lichen sclerosus in the request for reconsideration. Relevant medical records were requested but not provided.    The use of the requested drug to treat the provided diagnoses are off-label uses.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Saxenda 18 milligram/3 milliliter pen injection prescribed to treat weight loss. The plan denied the request because the drug was excluded from Medicare Part D. 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 record shows the enrollee was prescribed Saxenda for the treatment of weight gain. We determined the plan is not required to cover Saxenda because it is excluded from coverage under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Neupro 4 milligram per 24 hour patch to treat restless leg symptoms. 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.Neupro is a brand drug on Tier 4 of the plans formulary. 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.