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

At issue is Combigan 0.2/0.5% solution prescribed twice daily for the treatment of elevated intraocular pressure secondary to bilateral open angle glaucoma. The Part D plan denied your request for a tiering exception because Combigan 0.2/0.5% solution is a Tier 3 medication with no alternate drugs on a lower tier. 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. You submitted a prescriber statement, which indicates that the enrollee has tired Travatan Z and Timolol maleate. You have indicated that the enrollees elevated intraocular pressure is no longer controlled with Travatan Z and Timolol maleate. You have also indicate that the enrollees condition improved with a sample of Combigan 0.2/0.5% solution. The records show Combigan 0.2/0.5 solution 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 Combigan 0.2/0.5% solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Dofetilide 500 micrograms prescribed daily for a heart arrhythmia. 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. 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 Medicare approved compendium shows Dofetilide is a tier 4 generic drug prescribed to treat atrial fibrillation.  The prescriber has not addressed why all available lower tier alternatives to treat the enrollees condition would not be as effective as the requested drug. Therefore, Dofetilide 500 micrograms is not eligible for a tiering exception.  A physician reviewed your appeal and determined that the plan is not required to provide a tiering exception for Dofetilide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ibrance 100 milligrams prescribed 21 tablets for 28 days for a diagnosis of breast cancer. The Part D Plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible 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 record indicates your physician prescribed Ibrance for your diagnosis of breast cancer. The Medicare approved compendia do contain citations to support this is a covered diagnosis. Ibrance is a brand drug on Tier 5 (specialty tier) of the plans formulary. Drugs listed on the specialty tier of a plans formulary are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Ibrance at a lower cost-sharing tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Motefil 500 milligrams prescribed three times daily for chronic interstitial lung disease. The Part D plan denied the request because it does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The record shows you were prescribed Mycophenolate Motefil 500 milligrams three times daily for chronic interstitial lung disease. However, the Medicare approved compendium does not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Mycophenolate Motefil because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Flovent HFA 110 milligrams prescribed daily for Covid-19. The Part D plan denied the request because it does not meet the criteria of a medically accepted indication. We received an expedited 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 record shows you were prescribed Flovent HFA 110 milligram daily for Covid-19. However, the Medicare approved compendium, do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Myocophenolate Mofetil, 250 milligrams, one tablet prescribed four-times-daily to be taken by you after your lung transplant. The Part D plan denied your request because the medication is approved by the Food and Drug Administration for after a kidney, heart, or liver transplant. It is not approved after a lung transplant. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Myocophenolate Mofetil to treat your condition following your lung transplant on September 3, 2016. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that your plan is not required to cover Myocophenolate Mofetil following a lung transplant.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Imbruvica, two 140 milligram capsules prescribed daily for chronic lymphocytic leukemia. You asked the Part D plan to provide a tiering exception. Your plan denied the request because the drug you are taking was not eligible for tier cost sharing exception. Imbruvica is on the Specialty Tier 4 of your plan. Your plan does not lower the cost sharing amount for drugs in this tier. Therefore, Imbruvica was excluded from a copay reduction.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The records show Imbruvica is being prescribed for chronic lymphocytic leukemia. The Medicare approved compendium supports the use of the requested drug for your condition. Imbruvica is a brand name drug on Tier 4 of your plan's formulary. There are no brand name drugs of the same type on the lower cost sharing tiers. Therefore, the requested drug is not eligible for a tiering cost sharing exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Gammagard solution 10 grams per 100 milliliters prescribed 2000 for 28 days for chronic inflammatory demyelinating polyneuritis. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Gammagard for chronic inflammatory demyelinating polyneuritis.Drugdex, a Medicare approved compendia, states the following: Gammaked(TM), Gamunex(R)-C, and Privigen(R) immune globulin are indicated for the treatment of chronic inflammatory demyelinating polyneuropathy (CIDP) in adults to improve neuromuscular disability and impairment and for maintenance therapy to prevent relapse.  Therefore, Gammagard is being prescribed for the treatment of a medically accepted indication. Gammagard is not on the Plan's formulary.  The prescriber has not stated that all the alternatives on the Plan's formulary to treat the enrollee's condition have been tried and failed, were ineffective or contraindicated. The plan is not required to cover the requested drug Gammagard.
Appeal type: Prescription Drug
Decision: Favorable

You requested methylphenidate HCL 5 milligrams prescribed once daily for demyelination-related fatigue. 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 records show your doctor prescribed methylphenidate HCL to treat your demyelination-related fatigue. Review of the Medicare compendia reveal a citation regarding use of this drug for your condition. You have multiple Sclerosis, which is considered a neurologic disease of central origin. The article is: Sleep. 2007 Dec;30(12):1705-11. Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. It states  Based on evidence and/or long history of use in the therapy of narcolepsy committee consensus was that modafinil, amphetamine, methamphetamine, dextroamphetamine, and methylphenidate are reasonable options for the therapy of hypersomnias of central origin.A physician reviewed your appeal and determined that this is a medically acceptable indication. The plan's prior authorization were not met, however a prior authorization exception is granted.The decision is therefore to approve coverage for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested cyclophosphamide 50 milligram tablets prescribed 20 tablets for 28 days for multiple myeloma. The Part D plan denied your request because the drug at issue is covered under Medicare Part B. 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 shows your physician prescribed cyclophosphamide to treat your diagnosis of multiple myeloma. The Medicare approved compendium supports this is a medically accepted indication for the drug. However, the drug at issue is an oral cancer drug that has the same active ingredient as an injectable drug that is not self administered. Oral cancer drugs that contain the same active ingredient as injectable dosage forms are covered under Medicare Part B. The drug at issue is not considered a Part D benefit.We determined that the plan is not required to cover the cyclophosphamide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vimpat 200 milligram tablets prescribed twice daily for seizure disorder. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for a tiering exception. 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. Vipmat is a brand drug on Tier 5 (specialty tier) of the plans formulary. Drugs listed on the specialty tier of a plans formulary are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Vipmat at a lower cost-sharing tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate mofetil 200 milligram per milliliter suspension prescribed for cicatricial pemphigoid. The Part D Plan denied your request for a tiering exception because the drug requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Mycophenolate mofetil is a generic drug on Tier 3, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the specialty tier from the tiering exception process. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate mofetil. A tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azathioprine 100 milligrams prescribed daily for immune thrombocytopenic purpura. The Part D plan denied your request because it does not meet the criteria of 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Azathioprine 100 milligrams daily to treat your immune thrombocytopenic purpura. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover Azathioprine 100 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pregabalin 50 milligrams prescribed 15 tablets for 30 days for chronic pain. 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 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.Your medical records show your doctor prescribed Pregabalin to treat your chronic pain and pain in your left shoulder. 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 Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyzulta 0.024 percent eye drops prescribed nightly for primary open angle glaucoma. The Part D plan denied your request to cover this drug at a lower tier cost. The plan indicated this is a non-formulary drug and cannot be provided at a lower tier cost. 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. The record shows Vyzulta was prescribed to treat open angle glaucoma.   Vyzulta is a non-formulary approved drug and is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the Vyzulta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine Hydrochloride 8 milligram sublingual tablet three times daily for chronic pain. The Part D plan denied your request because the medication is not prescribed for a medically accepted indication. 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. The record shows you are prescribed Buprenorphine Hydrochloride 8 milligram sublingual tablets to treat chronic pain for long-term daily around-the-clock opioid analgesia. However, the Medicare approved compendia do not support the use of this drug in the form prescribed for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride 8 milligram sublingual tablet. We cannot consider overturning the prior authorization criteria for a drug the Part D plan is unable to cover.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 4.5 milligram tablets prescribed daily for bipolar disorder. The Part D Plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible 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 record indicates your physician prescribed Vraylar for your diagnosis of bipolar disorder. Vraylar is a brand drug on Tier 5 (specialty tier) of the plans formulary. Drugs listed on the specialty tier of a plans formulary are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Vraylar at a lower cost-sharing tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Diclofenac Sodium 1 percent, 100-milligram topical gel prescribed for costochondral symptoms. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received an expedited 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. We also researched Medicare systems and reviewed the enrollment data available.The record shows you were prescribed Diclofenac Sodium for costochondral symptoms. In review of the Medicare approved compendium, costochondral symptoms is not a medically accepted indication for Diclofenac Sodium. A physician reviewed your appeal and determined that the plan is not required to cover the Diclofenac Sodium at issue because it does not meet the definition of a Part D drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Votrient 200 milligrams prescribed four times daily for non-small cell lung cancer. The Part D plan denied your request because the medication is not prescribed for a medically accepted indication. 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. The records show that you prescribed Votrient to treat the enrollees non-small cell lung cancer. 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 Votrient.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eliquis, one 5 milligram tablet prescribed twice daily for anticoagulation therapy. The Part D plan denied a tiering exception because your plan does not cover Eliquis for your condition. The plan does not include Eliquis on the formulary. However, the plan did approve Eliquis under a formulary exception as a non-formulary drug. The prescriber stated that the member could not afford the cost of Eliquis and would be on this type of drug for life. Coumadin, the alternative drug, was not an option for the member because the member developed a blood clot while on Coumadin in the past. The plan further stated that Medicare does not grant a tiering exception (reduction in co-pay) for a non-formulary drug approved as a formulary exception. As such, Eliquis did not qualify for a tiering exception per Medicare rules. We received an expedited tiering exception request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Eliquis as your anticoagulation therapy. The Medicare approved compendium supports the use of the requested drug for your condition. However, Eliquis is a brand name drug that is not covered by your plan. Additionally, your plan approved Eliquis for you to take under a formulary exception as a non-formulary drug. There are no brand name drugs of the same type on the lower cost-sharing tiers for you to try. Lastly, Medicare does not allow a tiering exception for a non-formulary drug that is approved as a formulary exception. Therefore, the requested drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that your plan is not required to grant a tiering exception (reduction in co-pay) for Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Guanfacine Hydrochloride 1 milligram twice daily for impulsivity secondary to disruptive behavior disorder, pervasive developmental disorder, and intellectual disability. The Part D plan denied your request because the medication is not prescribed for a medically accepted indication. 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. The record shows you prescribed Guanfacine Hydrochloride to treat the enrollees impulsivity. 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 Guanfacine hydrochloride 1 milligram. We cannot consider overturning the quantity limitations for a drug the Part D plan is unable to cover.