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

Tadalafil 10 milligram tablet was requested to treat the enrollee's condition.  The Part D plan denied your 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 your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis, to address the nonformulary criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.  A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dofetilide 250 microgram capsules. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Dofetilide is a generic drug on Tier 4 of the plans formulary. We requested additional information from your prescriber but did not get a response. Your doctor did not address why all of the drugs available on the lower tiers of your plans formulary would not work for you. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto Tablet 24/26 milligram tablets prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. 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 Sildenafil Citrate 20-milligram tablet to treat pulmonary hypertension. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation provided addressed the plans coverage criteria, and those criteria were not satisfied. 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 Vyzulta 0.024% eyedrops. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ocetreotide Acetate solution 50 micrograms/milliliter prescribed for small bowel arteriovenous malformation and gastrointestinal bleeding. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Ocetreotide Acetate for small bowel arteriovenous malformation and gastrointestinal bleeding. 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 Ocetreotide Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Otezla 30 milligram tablets prescribed for plaque psoriasis. The Part D plan denied your 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 that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% ointment prescribed for peripheral neuropathy of unspecified origin. The Part D plan denied your 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 did not include medical records or a prescriber supporting statement. A request for additional documentation was sent to your doctor. A supporting statement and medical records were received. The documentation indicates your doctor prescribed Lidocaine ointment for peripheral neuropathy of an unspecified origin. The Medicare approved compendia do not support the use of the drug for your condition. As it cannot be determined that the drug was 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 a request for coverage of Neulasta Onpro 6 milligram per 0.6 milliliter subcutaneous injection kit prescribed for ovarian cancer and chemotherapy-induced neutropenia prophylaxis. 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 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.Neulasta Onpro is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition 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

At issue is Contrave 8-90-milligram tablet to treat obesity. The case was auto-forwarded by the plan.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 to treat weight gain (promote weight loss) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.A physician reviewed the appeal and determined that the requested drug is excluded from Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Enbrel 25 milligram/0.5 milliliter solution prefilled syringe prescribed as directed for reactive arthritis (Reiter's Syndrome) and sacroiliitis. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Enbrel to treat your reactive arthritis (Reiter's Syndrome) and sacroiliitis. 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 Enbrel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Onfi suspension 2.5 milligrams/milliliter 480 milliliters per 30 days prescribed for refractory epilepsy. The Part D plan denied the request because it does not meet the plans 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, you requested Onfi suspension 2.5 milligrams/milliliter 480 milliliters per 30 days, prescribed for refractory epilepsy. Medical records document extensive medical and surgical interventions for control. A citation in Micromedex, a Medicare approved compendium, supports the use of the requested drug for the condition indicated:  Adjunctive therapy with clobazam has been effective in the treatment of uncontrolled or refractory epilepsy in adults and children. Therefore, it is considered a medically accepted indication. However, the drug requested is not on the plans formulary.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives (including generic clobazam) 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 Carisoprodol 350 milligram oral tablet prescribed three time daily for rheumatoid arthritis and muscle spasms. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary such as Tizanidine would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Carisoprodol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine Hydrochloride 8 milligram sublingual tablet for chronic pain. 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 record shows your physician prescribed Buprenorphine Hydrochloride 8 milligram sublingual tablet to treat chronic pain. However, the Medicare approved compendia do not support the use of this drug form for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride 8 milligram sublingual tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec 75 milligram disintegrating tablets prescribed for the enrollees condition. The Part D plan denied your 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.Nurtec is a non-formulary brand drug. Non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Methadone Hydrochloride 10 milligram tablets, 90 tablets per 30 days, prescribed for chronic phantom limb pain and stump pain of the left lower extremity. The Part D plan denied the request because the prescriber did not provide the maximum daily opioid dose needed to manage the enrollees pain.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The plan's formulary limits the amount of opioids to less than 200 morphine equivalents on hand per day. A prescription for 90 tablets per 30 days of 10 milligram Methadone Hydrochloride tablets is equivalent to 240 morphine milligrams on hand per day. The documentation does not support exceeding the morphine milligram equivalent dose per day quantity limit as outlined in the plans formulary. A physician reviewed your appeal and determined that the plan is not required to cover 90 tablets per 30 days of 10 milligram Methadone Hydrochloride tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested NP Thyroid 60 milligram tablets prescribed as directed. 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 record shows the physician prescribed NP Thyroid. NP Thyroid has not been approved by the Food and Drug Administration. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.We determined that the plan is not required to cover NP Thyroid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vraylar 1.5 milligram capsules prescribed as directed for other specified depressive episodes. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Vraylar to treat your other specified depressive episodes. 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 Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz XR 11 milligram oral tablet prescribed for rheumatoid arthritis. 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. We received the documentation and included it in our review.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. Your prescriber submitted a supporting statement. However, no medical records were submitted to support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz XR.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Kineret 100 milligram per 0.67 milliliter syringe prescribed for severe intractable seizures and memory impairment related to new onset refractory status epilepticus. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Kineret to treat your severe intractable seizures and memory impairment related to new onset refractory status epilepticus due to anti-glutamic acid decarboxylase (GAD) antibody autoimmune limbic encephalitis. However, the Medicare approved compendia do not support the use of this drug for your condition. The formulary exception was not addressed because 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 Kineret.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablets prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Eliquis is a brand drug on Tier 2 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 Cevimeline Hydrochloride 30 milligram oral tablet prescribed three times daily for keratoconjunctivitis sicca, not specified as Sjogrens bilateral. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Cevimeline Hydrochloride to treat your keratoconjunctivitis sicca in both eyes not due to Sjogrens syndrome. 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 Cevimeline Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Durezol 0.05 percent drops prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.This drug is not included on your plans formulary. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Mesalamine DR 1.2 gram delayed release tablets prescribed for ulcerative colitis. 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 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. Mesalamine DR is a generic drug on Tier 4 of the plans formulary. The prescriber has not sufficiently addressed all of the generic drugs on the lower tiers of the plans formulary to treat ulcerative colitis. The prescriber has not explained why each lower tier alternative has been tried and failed or is contraindicated. A physician reviewed the appeal and determined that the plan is not required to cover the Mesalamine DR at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Belbuca 75 microgram buccal films prescribed for herniated cervical and lumbar discs. The Part D plan denied your 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 did not include medical records or a prescriber supporting statement. A request for additional documentation was sent to your doctor. A supporting statement was received; however, medical records were not received. As it cannot be determined that the drug was 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 Viberzi 100-milligram tablet to treat high output ileostomy, ileostomy, and resection of small bowel. The Part D plan denied the request stating that the provided diagnoses are non-medically accepted indication. 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.At reconsideration a diagnosis of irritable bowel syndrome with diarrhea was given. No medical records were provided by the prescriber to support this diagnosis. The use of the requested drug to treat the provided diagnoses are off-label uses. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.