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

At issue is Testosterone, 12.5 milligrams/actuation (1%) gel for the treatment of male hypogonadism. The Part D plan denied coverage of the medication stating that Medicare Part D drug plans cannot cover drugs used for the treatment of sexual or erectile dysfunction.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 medical records submitted at reconsideration show your doctor prescribed the Testosterone gel to treat male hypogonadism. The Medicare approved compendia do support the use of this drug for your condition. Your Part D drug plan requires certain conditions to be met before they will cover the Testosterone gel. To meet these requirements, your doctor must confirm that you have had at least two low testosterone levels before starting treatment. Your doctor has submitted laboratory results with the reconsideration file that show you have had two confirmed low testosterone levels prior to treatment. Therefore, the documentation provided by your physician supports that that you have a medically accepted indication, male hypogonadism, for the Testosterone gel. Additionally, the laboratory results confirm your condition and satisfy the plans prior authorization requirements.A physician reviewed your appeal and determined that the plan is required to cover the Testosterone gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligram tablets prescribed twice daily for chronic inflammatory demyelinating polyradiculoneuropathy. The Part D plan denied your request because this drug was not prescribed for 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. Your medical records show your doctor prescribed Mycophenolate Mofetil to treat your chronic inflammatory demyelinating polyradiculoneuropathy. 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Methotrexate Sodium vial 25 milligrams per milliliter prescribed due to inflammatory degenerative arthritis. 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 Methotrexate Sodium for inflammatory degenerative arthritis. In review of the Medicare approved compendia, inflammatory degenerative arthritis is not a medically accepted indication for Methotrexate Sodium.A physician reviewed your appeal and determined that the plan is not required to cover the Methotrexate Sodium at issue because it does not meet the definition of a Part D drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Modafinil 100 milligrams for excessive daytime sleepiness disorder. 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 Modafinil for excessive daytime sleepiness disorder. The diagnosis of excessive sleepiness disorder related to depression and fatigue was added after reconsideration. No documentation to support this diagnosis was submitted. The Medicare approved compendia does not support the use of the requested drug to treat excessive daytime sleepiness. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Modafinil at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 60 milligram tablet prescribed daily. The Part D plan denied your request for a tiering exception because the requested drug is in the highest specialty tier and the plan does not allow drugs in this tier at a lower cost-share. 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. Latuda 60 milligram tablet is a brand drug on Tier 5 of the plans formulary. However, Latuda is on the specialty tier of the plans formulary. Drugs on this tier are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Latuda 60 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lumigan 2.5 milligrams/vial prescribed for glaucoma. The Part D Plan denied your request for a tiering exception because there were no other alternatives of the same type on a lower tier. 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. Lumigan is a brand drug on Tier 3 of the plans formulary. The documentation supports the Lumigan was prescribed for glaucoma. 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 Lumigan at a lower cost-sharing tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trintellix 10 milligrams prescribed daily. The Part D plan denied your request for a tiering exception. We received an auto-forwarded reconsideration request from the coverage level. 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 that Trintellix 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 reimburse you for the Trintellix 10 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 145 micrograms prescribed daily for constipation. 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. Linzess 145 micrograms 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 cover Linzess 145 micrograms 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 Glassia 1 gram/50 milliliters prescribed as directed for alpha-1-antitrypsin deficiency. The Part D plan denied your request because the prior authorization requirements were not met. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The record shows that your doctor prescribed Glassia 1 gram/50 milliliters to treat your alpha-1-antitrypsin deficiency. The Medicare approved compendia support the use of this drug to treat your condition. However, your doctor submitted a prescribers statement that shows no other drugs on the plans formulary have been tried to treat your condition. Your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Glassia because your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligrams prescribed daily for non-24 hour sleep-wake disorder. 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 records show Hetlioz was presribed to treat non-24 hour sleep-wake disorder. The Medicare approved compendia do support the use of this drug for this condition. However, the plan requires that the patient is totally blind, or has no light perception, before they will cover the requested drug with prior authorization. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Acthar Gel, 400 units per 5 milliliter vial, prescribed to be given twice-weekly subcutaneously for your polymyositis. The Part D plan denial stated that this was not a medical necessity denial. Your plan only covers this drug when a pharmacy dispenses it directly to you. Your Part B covers this drug when you get the drug from your doctors office, an infusion center, in a hospital outpatient department, or if the pharmacy sends the drug directly to your doctors office. Drugs covered by Part B cannot be covered by Part D. 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 availableYour record shows that you are receiving 80 units of Acthar, administered subcutaneously, twice-weekly in your doctors office. The drug is non-self-administered and sent from your pharmacy to your doctors office for them to give to you. Medicare and your plan do not pay for drugs that are sent to your doctors office. This is not to say that Acthar is not medically necessary for your condition. This only informs you that Medicare Part D does not pay for drugs that you do not get directly from your pharmacy. A physician reviewed the appeal and has determined that your plan is not required to cover this drug. Medicare Part B is responsible for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Fanapt 12 milligrams prescribed as directed for schizoaffective disorder. The Part D plan denied the request because this type of drug is a specialty drug and is excluded from being provided at a lower cost 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. The record shows you were prescribed Fanapt 12 milligrams as directed for schizoaffective 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 the Fanapt because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Creon, 36000 unit capsule DR prescribed two times daily for exocrine pancreatic insufficiency. The Part D Plan denied your request for a tiering exception because the requested drug is listed at tier 2, which is the lowest cost share tier allowed by your plan for the drug. The plan was unable to offer a lower cost share for this 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 information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Creon DR is a brand drug on tier 2 of the plans formulary. The prescriber statement shows the drug was requested to treat exocrine pancreatic insufficiency. We asked our physician reviewer to determine whether the plan was correct in denying the request for a tiering exception for Creon DR. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception. Our physician reviewer's opinion is that tiering exception criteria are not met. Medicare rules permit a plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. The tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating your condition. Therefore, our decision is the plan is not required to provide a tiering exception for Creon DR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligram tablets ER 24 hour prescribed for urge incontinence. 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. Myrbetriq is a brand name drug on Tier 4 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.A physician reviewed your appeal and determined that the plan is not required to cover the Myrbetriq at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 0.5 milligrams, solution pen injector prescribed once a week for diabetes. 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. We also researched Medicare systems and reviewed the enrollment data available.The record shows Ozempic was being prescribed to treat the enrollee's condition.  Ozempic 0.5 milligrams, solution pen-injector 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 levels. We have determined that the plan is not required to provide a tiering exception.Our decision does not address medical necessity of the drug. We made our decision only on the fact that it is not eligible for a tier exception under the Medicare Part D benefit. 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 Ozempic 0.5 milligrams, solution pen-injector.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tramadol 50 milligrams prescribed once every six hours, as needed for secondary malignant neoplasm of retroperitoneum and peritoneum. You asked the Part D plan to provide coverage for Tramadol. 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 information submitted at the reconsideration level.Your medical records show your doctor prescribed Tramadol 50 milligram to treat pain for secondary malignant neoplasm of retroperitoneum and peritoneum. Medicare records show you are currently under hospice benefit care. We determined that the drug is not eligible for Part D coverage. Medicares hospice benefit should cover any prescription drugs you need for pain and symptom management related to your terminal condition, not your Part D plan. Therefore, this 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 Tramadol under the Part D plan. Medications that are covered under Medicare Part A (hospice) are not eligible to be covered under the Medicare Part D Prescription Drug benefit.You may wish to submit a request for Tramadol to the Medicare Part A (hospice) carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligrams prescribed twice daily for atrial fibrillation. The Part D Plan denied your request for a tiering exception because there are no lower tier brand alternatives 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.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 reimburse Eliquis at a lower tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Morphine Sulfate ER 75 milligram capsules prescribed for multiple sclerosis. 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. Your doctor submitted a supporting statement stating that the Morphine Sulfate ER was prescribed to treat significant pain as a result of your multiple sclerosis. The Medicare approved compendia support the use of the requested drug for your condition.However, the records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician has noted that you did try Oxycodone tablets and Fentanyl patches in the past, but were unable to tolerate them. However, there are other drugs listed on your plans formulary, to treat your condition that have not been tried.A physician reviewed your appeal and determined that the plan is not required to cover the Morphine Sulfate ER as an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% ointment prescribed as needed for vulvar pain secondary to vulvar lichen planus. The Part D plan denied your request because this medication is not prescribed for 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.The records show you prescribed Lidocaine 5% ointment for vulvar pain secondary to vulvar lichen planus. 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 lidocaine 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride, 10 milligram tablets to be taken three times per day for the treatment of polyosteoarthritis. The Part D plan denied your request because polyosteoarthritis is not a Food and Drug Administration-approved diagnosis for the use of this medication. We received an auto-forwarded reconsideration request from the coverage level. 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 documentation shows your doctor prescribed Cyclobenzaprine Hydrochloride for your polyosteoarthritis. 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 Cyclobenzaprine Hydrochloride.