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

At issue is mycophenolic acid 360 milligrams, delayed release tablet with a quantity of 180 tablets per 90 days prescribed following a kidney transplant. The Part D plan denied the request because this drug may be eligible for coverage under Part B; therefore, it cannot be covered under Part D. We received a request to reconsider the appeal.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 medical record shows mycophenolic acid 360 milligrams, delayed release tablet was prescribed with the diagnosis of kidney transplant immunosuppression. The medical records indicate the enrollee had a kidney transplant on June 9, 2011. According to Medicare records, you were enrolled in Medicare Part A at the time of the transplant. The tacrolimus is eligible for coverage under Medicare Part B. Drugs that are eligible for Part B coverage cannot be considered under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover or allow payment under your Medicare Part D benefit for mycophenolic acid 360 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is tacrolimus 1 milligram per 2 milliters with a quantity of 180 tablets per 90 days prescribed following a kidney transplant. The Part D plan denied the request because this drug may be eligible for coverage under Part B; therefore, it cannot be covered under Part D. We received a request to reconsider the appeal.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 medical record shows tacrolimus 1 milligram per 2 milliters was prescribed with the diagnosis of kidney transplant immunosuppression. The medical records indicate the enrollee had a kidney transplant on June 9, 2011. According to Medicare records, you were enrolled in Medicare Part A at the time of the transplant. The tacrolimus is eligible for coverage under Medicare Part B. Drugs that are eligible for Part B coverage cannot be considered under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover or allow payment under your Medicare Part D benefit for tacrolimus 1 milligram per 2 milliters.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symbicort, 160/4.5 microgram inhaler prescribed for chronic bronchitis. The Part D Plan denied your request for a tiering exception because there were no other brand drugs appropriate to treat your condition on a lower cost-sharing tier. 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 Symbicort at a lower cost tier.Symbicort 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. Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pradexa 150 milligram tablets prescribed for the diagnosis of paroxysmal atrial fibrillation. The Part D Plan denied your request for a tiering exception because the requested drug is already covered at the cost-sharing Tier listed in the 2021 Drug Guide and the providers statement did not explain why the alternative brand name drugs in a lower Tier wouldnt work just as well. 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 rules and the plans formulary.Pradexa is a brand drug on Tier 4 of the plans formulary. There are brand drugs of the same type on the lower Tiers of the plans formulary. The physician states that the enrollee has been on Pradexa for this condition for 2 years but does not indicate reasons why the brand name drugs, of the same type and on the lower Tiers, could not be effective. 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 Pradexa at a lower Tier cost.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Afrezza powder prescribed as directed for diabetes mellitus. The Part D plan denied your request for a tiering exception because the drug you requested is not included on your plans formulary.  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 you were prescribed Afrezza powder as directed for diabetes mellitus. The Medicare approved compendia support the use of this drug for your condition. However, since the drug isnt on the plans formulary it is not eligible for a tiering exception. 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 Afrezza powder.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is the Shingrix vaccine prescribed as a prophylaxis for herpes zoster. 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. We also researched Medicare systems and reviewed the enrollment data available. The record shows you were prescribed the Shingrix vaccine as a prophylaxis for herpes zoster. 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 the Shingrix vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Tacrolimus 1mg capsule, 720 capsules per 90 days, for prophylaxis of liver transplant rejection. 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.Tacrolimus is a generic drug on Tier 4 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

You requested Xeljanz 10 milligram table prescribed twice daily for alopecia capitis totalis. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. 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 medical records show your doctor prescribed Xeljanz to treat your alopecia capitis totalis. 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 Xeljanz. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Lotemax 0.5 percent eye ointment prescribed for edema of the eye (orbit), meibomian gland dysfunction of both eyes, and keratoconjunctivitis sicca. 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. The record shows you were prescribed Lotemax for edema of the eye (orbit), meibomian gland dysfunction of both eyes, and keratoconjunctivitis sicca. In review of the Medicare approved compendia, edema of the eye (orbit), meibomian gland dysfunction of both eyes, and keratoconjunctivitis sicca are not medically accepted indications for Lotemax. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the drug at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Clobazam 10 milligram tablet prescribed for general idiopathic epilepsy intract without status epilepticus. 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. The record shows you were prescribed Clobazam for general idiopathic epilepsy intract without status epilepticus. In review of the Medicare approved compendia, general idiopathic epilepsy intract without status epilepticus is not a medically accepted indication for Clobazam. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Clobazam at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol 180 milligram tablet prescribed for mixed hyperlipidemia. The Part D plan denied your request because the documentation did not support an off-formulary 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. The physician submitted a supporting statement. The prescriber statement shows the physician had prescribed Nexletol to treat hyperlipidemia. However, the records do not show why preferred alternatives on the plans formulary for the same condition have not been tried. Specifically, the prescriber statement indicates the enrollee failed treatment with Simvastatin. The documentation does not show that the enrollee has tried other formulary alternatives, or why the enrollee cannot take them.A physician reviewed your appeal and determined that the plan is not required to grant a off-formulary exception for the Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol 1 milligram prescribed for the enrollees vulvar vaginal atrophy. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription 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. 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 vulvar vaginal atrophy, which is a medically accepted indication. However, the enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria, as the prescriber did not indicate the enrollee had a trial with another drug considered to be safer first.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil 20 milligram tablets were prescribed for the enrollees erectile dysfunction. The Part D plan denied your request because cough and cold medications do not meet the definition of Part D 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 determined that the plan is not required to cover Sildenafil because it was used to treat sexual or erectile dysfunction. 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 Trelegy Ellipta prescribed as directed for chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception. 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. Trelegy Ellipta  is a brand drug on Tier 3 of the plans formulary. The prescriber statement shows you were prescribed Trelegy Ellipta for chronic obstructive pulmonary disease. 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 Trelegy Ellipta 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 Buprenorphine 8 milligram-Naloxone 2 milligram sublingual tablets. The Part D plan denied your request because the documentation did not support an off-formulary 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 shows you prescribed Buprenorphine 8 milligram-Naloxone 2 milligram sublingual tablets to treat the enrollees condition.  However, the records do not show why the enrollee cannot take other drugs on the plans formulary. You did not give specific medical reasons why the enrollee cannot use the preferred drug, Zubsolv.A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine 8 milligram-Naloxone 2 milligram sublingual tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mesalamine 4.8 grams prescribed daily for microscopic colitis. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. 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 Mesalamine was prescribed to treat microscopic colitis. Mesalamine is on the plans formulary specialty tier 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 Mesalamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Freestyle Libre 14 day sensor prescribed for type 2 diabetes mellitus. The Part D plan denied the request because drugs and medical supplies that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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 Freestyle Libre 14 day sensor was prescribed to treat diabetes mellitus. The requested medical supply is not directly associated with the injection of insulin and is eligible for coverage under Medicare Part B. We determined that the plan is not required to cover Freestyle Libre 14 day sensor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus SoloStar pen 100 units/milliliter prescribed as directed for diabetes mellitus. The Part D plan denied your request for a tiering exception. 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. Lantus SoloStar pen 100 units/milliliter is a brand drug on Tier 3 of the plans formulary. The prescriber statement shows you were prescribed Lantus SoloStar pen 100 units/milliliter for diabetes mellitus. 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 Lantus SoloStar pen 100 units/milliliter because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vyvanse 30 milligrams prescribed twice daily for major depressive disorder. The Part D plan denied your 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. Your medical records show your doctor prescribed Vyvanse 30 milligrams twice daily to treat your major depressive disorder. 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 Vyvanse 30 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tamoxifen 20 milligram tablets prescribed daily for bipolar disorder. 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 medical records show Tamoxifen was prescribed to treat bipolar disorder. The prescriber statement indicates the enrollee has bipolar disorder and has responded well to the drug at a higher dosage than used for breast cancer. However, the Medicare approved compendia do not support the use of this drug for this condition under the Food and Drug Administration approved uses or the off-label uses. The medical record does not include a medically accepted indication for the drug at issue. A physician reviewed your appeal and determined that the plan is not required to cover Tamoxifen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ciclopirox 8% solution, 6.6 milliliters prescribed daily for onychomycosis. The Part D plan denied your request for a tiering exception because an enrollee cannot request a lower cost share (tier) of a non-formulary drug approved under the Medicare Part D drug plan. 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.Ciclopirox 8% solution was approved by your plan as a non-forumlary exception on February 3, 2021.  Drugs that are approved for non-formulary exception 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 for Ciclopirox.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested thalidomide, 100-milligrams prescribed one capsule daily for anemia secondary to small bowel arteriovenous malformation. The Part D plan denied your request because the off-label use of this drug for your condition is not a medically accepted indication per Medicare rules.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 thalidomide to treat your anemia secondary to small bowel arteriovenous malformation. However, the Medicare approved compendia do not support the off-label use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover thalidomide because you do not have a medically accepted indication per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carafate 1gram/10 milliliter oral suspension. 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. We also researched Medicare systems and reviewed the enrollment data available. We attempted to obtain a supporting statement and medical records from your physician to support the off formulary drug. However, the office stated the Carafate 1gram/10 milliliter oral suspension has not been prescribed to you since October 9, 2018. We were unable to obtain the information necessary to approve your request for the off formulary drug. Therefore, the plan is not required to grant an off-formulary exception for the Carafate 1gram/10 milliliter oral suspension. A physician reviewed your appeal and determined that the plan is not required to cover Carafate 1gram/10 milliliter oral suspension because the documentation did not support an off-formulary exception.