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

At issue is Eliquis 5 milligram tablets prescribed as directed. 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.Eliquis 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 a request for coverage of Oxiconazole Nitrate 1% cream prescribed for tinea pedis.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. Oxiconazole Nitrate cream is not included in the plans formulary. During this review, a prescriber statement and supporting medical records were requested from the prescriber to address why the alternative medications that are included in the plans formulary to treat the noted condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. However, the prescriber did not respond to the request. 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 Clotrimizole-Betamethosone 1-0.05% cream prescribed for tinea cruris. The Part D plan did not make a decision.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.Clotrimizole-Betamethosone 1-0.05% cream is a generic drug on Tier 3 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 to grant your request for a tiering exception. The records show that the plan allowed Clotrimizole-Betamethosone 1-0.05% cream at the quantity limit of 45 grams per 30 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. A physician reviewed the appeal and determined that the quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pilocarpine Hydrochloride 7.5 milligram tablets prescribed to treat the enrollee's condition.  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.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 to treat the same condition. 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 Edarbyclor 40-25 milligram tablet prescribed daily for hypertension. 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.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. We received the documentation and included it in our review.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. A physician reviewed the appeal and determined that the plan is not required to cover Edarbyclor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for a tiering exception for Avalide 150-12.5 milligram tablets prescribed for hypertension. 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.Avalide is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Avalide at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 30 milligram tablets prescribed as directed. 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. This drug is 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Chlordiazepoxide and Amitriptyline Hydrochloride 5/12.5milligram tablet prescribed every eight hours for tension headache. 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 Chlordiazepoxide and Amitriptyline Hydrochloride to treat your headaches. 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 Chlordiazepoxide and Amitriptyline Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Econazole Nitrate 1% Cream to treat tinea pedis right foot. 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

At issue is a tiering exception request for Eliquis 2.5-milligram tablet to treat deep vein thrombosis. 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.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 Farxiga 10 milligram tablet. 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. We asked your prescriber to send us information about 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 similar medications on the lower teirs would not work for you. However, we did not receive the documentation.. Farxiga is a brand drug on Tier 4 of the plans formulary. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you. 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

Xeljanz was requested to treat the enrollees condition. The requested drug has prior authorization criteria. The case was auto-forwarded by 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.A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records. A reply from the prescriber was not received. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 420 milligrams per 3.5 milliliters Pushtronex system solution cartridge prescribed to treat coronary artery disease and high cholesterol. 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 prescriber indicates that a couple of the plans alternative formulary drugs were tried and failed or could cause harm. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the records do not support why all 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 Repatha 420 milligrams per 3.5 milliliters Pushtronex system solution cartridge.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsule prescribed daily for unspecified insomnia. 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.Hetlioz was prescribed to treat the enrollees unspecified insomnia. However, the Medicare approved compendia do not support the use of this drug for this long term condition. A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vimpat 200 milligram tablets prescribed as directed. 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.Vimpat  is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azopt 1 percent ophthalmic solution prescribed as directed. 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. Azopt 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 Nexletol 180 milligram tablets prescribed to treat high cholesterol. 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 Nexletol 180 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pred Mild 0.12% ophthalmic solution prescribed for steroid induced glaucoma and a history of corneal transplant. 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 Pred Mild 0.12% ophthalmic solution to treat the enrollees steroid induced glaucoma and history of corneal transplant. 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 Pred Mild 0.12% ophthalmic solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Imcivree 10 milligram per milliliter solution prescribed 3 milligrams subcutaneously daily for obesity due to leptin receptor deficiency. The Part D plan denied the request.We performed and 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.We determined that the plan is not required to cover Imcivree because it was used to treat obesity. Drugs to treat weight gain (promote weight loss) are excluded from coverage. The enrollees plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, they must pay for them. 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.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Diazepam10 milligram tablet prescribed for severe anxiety. 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 plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Your medical records show your doctor prescribed Diazepam to treat your severe anxiety. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: 'Diazepam is indicated for the management of anxiety disorder for the short-term relief of anxiety symptoms.'In the Reconsideration appeal dated May 25, 2021, the prescriber  provided a statement attesting that the concurrent therapy of a benzodiazepine and opioid pain medication is medically necessary. A physician reviewed your appeal and determined that the plan is required to cover Diazepam. The drug is medically necessary and prior authorization requirements have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica CR 82.5 milligram tablets prescribed for fibromyalgia. 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. Medicare approved compendium support the use of Lyrica CR for fibromyalgia. However, 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 Lyrica.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Octreotide Acetate 100 microgram per milliliter solution for subcutaneous injection. The Part D plan denied the request because the plans prior authorization requirements were not met due to the provided diagnosis. 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 Octreotide Acetate has been prescribed for the treatment of malabsorption due to Crohn's disease and short bowel syndrome with an ileostomy. 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 Octreotide Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Eszopiclone 2 milligram tablets prescribed for insomnia.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. Eszopiclone is not included in the plans formulary. During this review, a prescriber statement and supporting medical records were requested from the prescriber to address why the alternative medications that are included in the plans formulary to treat the noted condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. However, the prescriber did not respond to the request. 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 Exjade 125 milligram tablet prescribed daily for chronic iron overload. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. 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 Deferasirox would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Exjade.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Loteprednol Etabonate 0.5% suspension prescribed to treat dry eye syndrome associated with Meibomian gland dysfunction and blepharitis.  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 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, as ordered, is not being used for a medically accepted indication. The requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lubiprostone 8 microgram capsule prescribed for chronic idiopathic constipation. 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 Lubiprostone.