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

You requested Vascepa 1 gram capsules prescribed as directed for hypertriglyceridemia. 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 the doctor prescribed Vascepa to treat hypertriglyceridemia for an enrollee with a pre-treatment triglyceride level of 150 to 499 milligrams per deciliter. The prescriber statement also indicates the drug was prescribed to prevent cardiovascular events for an enrollee without a history of established cardiovascular disease or two risk factors for developing cardiovascular disease. The Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Alprazolam 1 gram capsules prescribed for an unspecified condition. The Part D plan denied your request because the medication was not approved by the United States Food and Drug Administration. 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 Alprazolam but the medical records submitted are for a different drug. We asked your doctor to send us a supporting statement to show why Alprazolam is medically necessary for you. No additional documentation was received.Since we do not have a diagnosis for this medication, we cannot determine if it is approved for use for your condition. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Alprazolam at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Procrit solution for anemia in end stage renal disease. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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. Based on the information provided, we determined the drug would be eligible for coverage under Part B under Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Gralise 300 milligrams prescribed for lumbago with sciatica, left side, and other chronic pain. 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 Gralise for lumbago with sciatica, left side, and other chronic pain. In review of the Medicare approved compendia, lumbago with sciatica, left side, or other chronic pain are not a medically accepted indications for Gralise. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Gralise at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta 50 milligram tablets prescribed for chronic back pain. 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. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Nucynta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24/26 milligram oral tablet prescribed twice daily for chronic systolic heart failure. 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. 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

You requested a lower cost tiering exception for Dofetilide 500 microgram capsules prescribed for paroxysmal atrial fibrillation. The Part D Plan denied your request because the documentation did not explain why the plans alternative drugs in lower tiers would not work just as well. 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. Dofetilide is a generic drug on Tier 4 of the plans formulary. The prescriber does not sufficiently address why all of the generic drugs of the same type on the lower tiers of the plans formulary to treat the enrollees condition have been tried and failed, or are contraindicated. Therefore, the plan is not required to grant a tiering exception for the Dofetilide.A physician reviewed your appeal and determined that the Dofetilide is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 20 milligram/10 milligram capsules prescribed for pseudobulbar affect. The Part D plan denied your request because the 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. The submitted documentation indicates your doctor prescribed Nuedexta for pseudobulbar affect not associated with amyotrophic lateral sclerosis or multiple sclerosis. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 Mycophenolate 500 milligrams tablets. The Part D plan denied a request for this drug because you did not have a medically accepted indication. We received an expedited reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The documentation indicates that Mycophenolate was prescribed to treat pemphigus vulgaris. 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 Mycophenolate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bystolic 5 milligram tablets. The Part D plan denied your request for a lower cost tiering exception.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.Bystolic is a brand drug on Tier 2 of your plans formulary. There are no brand drugs of the same type on the lower cost sharing tier. 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 Bystolic at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dexilant DR 60 milligram capsules prescribed for acid reflux, esophagitis, and hiatal hernia. The Part D plan denied your request for a tiering exception because Dexilant DR is a brand name Tier 4 drug and the lower cost-sharing tiers only contain generic alternative 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 also researched Medicare systems and reviewed the enrollment data available. The plan shows Dexilant DR is a brand name Tier 4 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligrams. 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 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 records submitted at the reconsideration level. The documentation provided contains a supporting statement from your doctor. The supporting statement did not satisfy the plan's prior authorization coverage criteria. The documentation does not include medical records to support a prescribed diagnosis. It cannot be determined the drug was prescribed for a medically accepted indication.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 Afinitor 5 milligrams tablets to treat cancer. The Part D plan denied your request for a non-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 records submitted at the reconsideration level. The prescriber has not indicated why all alternatives which are required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. 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

You requested Methylphenidate 10 milligram tablet prescribed as directed for symptoms of treatment resistant depression. The Part D plan denied the request because it does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The record shows you were prescribed Methylphenidate to treat your condition. 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 Methylphenidate because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24/26 milligram tablets prescribed for unspecified heart failure and ischemic cardiomyopathy. 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. 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 Oxycontin Extended Release 20 milligram tablet to treat your pain. The Part D plan denied the request. The requested drug is not on the plans formulary. We received an expedited 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 prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary 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 Farydak 10 milligram oral capsule prescribed for multiple myeloma. 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 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Farydak to treat multiple myeloma. The Medicare approved compendia do support the use of this drug for your condition.However, the plan requires the requested drug be given in combination with Bortezomib and Dexamethasone. 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 Farydak.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram oral tablet prescribed for chronic atrial fibrillation. The Part D plan denied your request for a tiering 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.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.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 a tiering exception for Budesonide 0.5 milligrams/2 milliliter nebulizer solution prescribed for severe persistent asthma. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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 the drug at issue is an inhalation solution for use with a nebulizer. Medicare Part B covers drugs used with nebulizers in the enrollees home. The drug is not eligible for coverage under Medicare Part D; therefore, a tiering exception cannot be allowed.We determined that the plan is not required to cover Budesonide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Suboxone 8 milligram/2 milligram sublingual film. At initial determination and redetermination the diagnosis of chronic pain syndrome was given as the indicated usage and confirmed on the prior authorization document. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication(s). 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. At reconsideration, a diagnosis of opioid dependence was added. In a letter dated March 15, 2021, it is indicated that the requested drug will be used to wean the enrollee from the current long acting pain medications to improve both neuropathic and mechanical pain. This is not a medically accepted indication. 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 Suboxone.
Appeal type: Prescription Drug
Decision: Favorable

Jakafi 5 milligram tablets, 60/30 was requested for hemorrhagic thrombocythemia. The Part D plan denied the request because it does not meet the plans prior authorization criteria. 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 regulations and Medicare approved compendia. At reconsideration Jakafi 5 milligram tablets, 60/30 was requested for chronic myelomonocytic leukemia  C93.10, per the office note of March 8, 2021.  A citation in NCCN, a Medicare approved compendium, supports the use of the requested drug for the condition indicated. Therefore, it is considered a medically accepted indication. The documentation does not satisfy the plans coverage criteria. The plans coverage criteria state that you need to have an FDA approved indication.  Therefore, an exception to the plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Myrbetriq ER 50 milligram tablets prescribed for overactive bladder. The Part D plan denied your request for a tiering exception because Myrbetriq ER is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative 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 also researched Medicare systems and reviewed the enrollment data available. The plan shows Myrbetriq ER is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Lokelma powder packet prescribed for hyperkalemia. The Part D plan denied your request for a tiering exception because Lokelma is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative 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 also researched Medicare systems and reviewed the enrollment data available. The plan shows Lokelma is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Propylthiouracil 50 milligram tablets prescribed for hyperthyroidism. 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.Propylthiouracil 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. 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 Propylthiouracil at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 49/51 milligram tablets prescribed for chronic systolic heart failure. 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. 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.