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

At issue is Xifaxan 550 milligram tablets prescribed to treat irritable bowel syndrome with diarrhea. 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 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 submitted documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans prior authorization criteria. 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 Enbrel 50 milligrams/milliliter prescribed as directed for psoriasis. 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. 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 the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. 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 Enbrel because a tiering exception cannot be granted for a drug on the Specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 1.5 milligrams prescribed as directed for major depressive disorder recurrent unspecified. 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. 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 the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. 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 Vraylar because a tiering exception cannot be granted for a drug on the Specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pramipexole one milligram tablet prescribed for restless leg syndrome. The Part D plan denied your request for a tiering exception because there are no lower tier alternatives of the same type for your condition. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Pramipexole is a generic drug on Tier 2 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Butalbital/Acetaminophen/Caffeine 50-325-40 milligram tablet prescribed for tension headaches. The plan denied the appeal because this drug is not listed on your formulary plan (non-formulary). 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. Your medical records show your doctor prescribed Butalbital/Acetaminophen/Caffeine for your tension headaches. This drug is not listed in your plans formulary. Therefore, the requested drug cannot receive a cost-sharing tiering formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Butalbital/Acetaminophen/Caffeine because the documentation does not show that you have met the coverage criteria for a cost-sharing tiering formulary exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cinacalcet hydrochloride 60 milligrams, prescribed two tablet per day to treat the diagnosis of secondary hyperparathyroidism of renal origin withcin end-stage renal 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 prescribed to treat the enrollees condition. The medical records also indicate the enrollee is receiving dialysis. Therefore, we have determined that the drug is not eligible for Part D coverage, but would be covered under Medicare Part B.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 Levalbuterol 0.63 milligrams per 3 milliliter prescribed to treat the enrollees condition. The Part D plan denied your request because the documentation did not support a covered 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. We asked the prescriber to send us a supporting statement and medical records to show why the drug is required. We received a prescriber statement and included it in our review. However, we did not receive medical records to support the statement and determine if the drug is eligible for coverage under the Part B benefit.A physician reviewed your appeal and determined that the plan is not required to cover Levalbuterol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Stelara Solution 90 milligram/milliliter Prefilled Syringe to treat Crohns Disease. The Part D plan denied the request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is being provided by the plan at the cost sharing level of the Specialty Tier. Specialty Tier drugs are not available for a tiering exception per Medicare rules.  Our Physician Reviewers opinion is that the plan is not required to provide a tiering exception for Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide inhalation solution 0.5 milligrams per 2 milliliters, quantity 180 for 30 days prescribed for chronic pansinusitis. The Part D plan denied a request for this drug because you did not have 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. Budesonide inhalation solution was prescribed to treat chronic pansinusitis and acute recurrent ethmoidal sinusitis. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s).A physician reviewed your appeal and determined that the plan is not required to cover Budesonide inhalation solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligrams prescribed two tablets twice daily for sicca syndrome, interstitial lung disease, and psoriasis. The Part D plan denied your request because the diagnoses provided do not meet the requirements of a Food and Drug Administration medically accepted indications. 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. Your medical records show your doctor prescribed Mycophenolate Mofetil to treat your sicca syndrome, interstitial lung disease related to sicca syndrome, and psoriasis. However, the Medicare approved compendia do not support the use of this drug for your conditions. A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate Mofetil because your diagnoses do not meet the Medicare requirement of medically accepted indications.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a 98-day supply of Repatha 140 milligram/milliliter single dose pre-filled auto-injectors. The Part D plan denied your request for a 98-day supply because the drug has a quantity limit of 3 per 28-days. 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 plan allows a supply of 3 per 28-days at a time. We requested medical records from the prescriber to confirm the enrollees condition and why they required an exception to the plans quantity limit restriction. This information was not received. Therefore, the plan is not required to cover a 98-day supply of Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gentamicin Sulfate 80mg/100 ml solution for nasal rinses daily prescribed for chronic sinusitis. The Part D plan denied your request because the drug was not used to treat 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 Gentamicin Sulfate solution for nasal rinses to treat your chronic sinusitis. 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 the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Flector 1.3 percent patch prescribed for swelling in both wrists. 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 Flector 1.3 percent patch to treat your swelling in both wrists. 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 Flector 1.3 percent patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benzonatate 200 milligram capsule prescribed for cough.   The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed for the symptomatic treatment of cough and colds are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ofev 150 milligram oral capsules prescribed twice daily for idiopathic pulmonary fibrosis. 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 at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine 50 milligram tablet prescribed four-times-daily for chronic back pain. The Part D plan denied your request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Hydroxyzine as a catalyst/enhancer to treat your chronic back pain. 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 Hydroxyzine because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 50 milligram tablets prescribed daily for benign prostatic hyperplasia with lower urinary tract symptoms. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Myrbetriq ER 50 milligram tablets are 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 cover Myrbetriq ER 50 milligram tablets 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 Entresto 24-26 milligrams prescribed for heart failure. The Part D plan denied coverage. The plan requires prior authorization requirements be met before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an 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. A physician reviewed your appeal and determined that the plan is not required to cover the Entresto. The Medicare approved compendia does support the use of this drug for heart failure. However, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria for prior authorization.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 49-51 milligram tablets prescribed as directed for congestive heart failure. The Part D plan denied your request for a tiering exception because there were no brand drugs of the same type on the 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. Entresto 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 Repatha Sureclick 140 milligrams/milliliter Auto-Injection to treat hyperlipidemia. The Part D plan did not provide a timely redetermination decision. We received an 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 records submitted at the reconsideration level. The prescriber has not submitted the most recent cholesterol laboratory report and there was no documentation the enrollee first tried a high intensity statin medication or was intolerant to a high intensity statin and at least two statins at the maximally tolerated dose were tried without reaching the LDL goal.  The documentation provided does not show the prior authorization criterion has been satisfied.Our Physician Reviewer has determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Free Style Libre 14 Day Sensor for the diagnosis of type 2 diabetes mellitus. The Part D plan denied the request. We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The device is subject to Part B benefits and is not eligible to be covered under the Medicare Part D prescription drug benefit. We have determined that the plan is not required to cover the Free Style Libre 14 Day Sensor under the Part D prescription drug benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trelegy Ellipta to treat chronic obstructive pulmonary disease. The Part D plan denied your request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the plans formulary.Trelegy Ellipta is a brand drug on Tier 3 of the plans formulary. However, 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: Favorable

At issue is Hydrocodone Bitartrate and Acetaminophen 5/325 milligram tablets prescribed as 90 tablets per 30 days to treat low back pain and cervicalgia. The Part D plan denied the request stating the information from your prescriber to verify that more than a 7 day supply is needed was not received. We received a reconsideration request from the plan. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The plans coverage rules indicate that Hydrocodone Bitartrate and Acetaminophen 5/325 milligram tablets are covered at 240 tablets per 30 days. The amount requested is within the plans maximum daily quantity limits. The prescriber states that the enrollee takes 1 tablet every 8 hours as needed and ordered a refill of 90 tablets per 30 days as the enrollee has been stable on the medication.  Our Physician Reviewer determined that the plan is required to cover 90 tablets per 30 days of Hydrocodone Bitartrate and Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ingrezza 40 milligram capsules at a quantity of 180 tablets per 90 days to treat tardive dyskinesia. The Part D plan denied the request. We received a reconsideration request from the plan. 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 plan approved the drug for 60 capsules per 30 days. The plan limits the amount of the drug to a recurring 30 day supply. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewers opinion is that the plan is not required to cover the drug greater than its quantity limit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligrams prescribed for the diagnosis of atrial fibrillation. The Part D plan denied your request for a tiering exception. We received a request to reconsider the appeal.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. Eliquis 5 milligrams is a brand name on Tier 3 of the plans formulary. There are no brand names of the same type on the lower cost-sharing levels. We have determined the requested drug is not eligible for a tier exception 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: Unfavorable

At issue is Nicotine Patch 21 milligrams per 24 hours. 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. Drugs prescribed that are available Over the Counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.