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

You requested Armodafinil 250-milligram tablets prescribed for idiopathic hypersomnia. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The Medicare approved compendia does not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees diagnosis.  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 Armodafinil. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mavyret 100-40 milligram tablet ordered three tablets daily for chronic hepatitis C. The Part D plan denied the request because the records did not include hepatitis B surface antigen testing. 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 records show Mavyret was ordered to treat the enrollees condition. The Part D plan approved the drug as off-formulary based on the fact that patients current medication would not allow formulary alternatives to be used. This is confirmed based on the information provided. Hepatitis B testing was completed and confirmed the enrollee was immune to Hepatitis B. Prior authorization criteria were satisfied.A physician reviewed your appeal and determined that the plan is required to cover Mavyret.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 100 microgram tablets prescribed daily for hypothyroidism. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Synthroid 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. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carbidopa 25 milligram tablets prescribed daily for Parkinson's disease. 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 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. 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 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 Tacrolimus 0.5 milligram capsules to treat the enrollees condition. 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. We also researched Medicare systems and reviewed the enrollment data available.The medical records show the requested drug is being prescribed to treat the enrollees condition. The enrollees medical history includes a liver transplant in November 1998. According to Medicare, the enrollee was under Medicare Part A coverage at the time of the liver transplant. Based on the information provided, we have determined the requested drug is not eligible for Medicare Part D coverage, but would be covered under Part B.A physician reviewed your appeal and determined that the requested drug is not eligible for Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Estrogen Methyltestos 1.25/2.5 milligram tablet prescribed every other daily for estrogen replacement therapy. The Part D plan denied your request because the requested drug is not considered a Part D covered drug. 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 determined that the plan is not required to cover Estrogen Methyltestos because it is not an approved Food and Drug Administration drug. The drug has not been found safe and effective by the Food and Drug Administration. A covered Part D drug must be approved by the Food and Drug Administration. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 100 milligram tablets. The Part D plan denied coverage because the prior authorization requirements were not met, as the enrollee had 15 or more headache days per month. 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. While the submitted medical records and prescriber statement support that the enrollee does have less than 15 migraine headache days per month, the documentation does not satisfy the plans additional coverage criteria for Ubrelvy. The prescriber has not sufficiently addressed all of the plans requirements for coverage of this medication. 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 Fentanyl 50 mcg/hour patch (15 patches per 30 days) to treat pain.  The Part D plan denied coverage because there was insufficient documentation to support the quantity requested and insufficient documentation to support the morphine milligram equivalent (MME) requested.  The plan requires prior authorization for quantities exceeding morphine milligram equivalent of 200 milligrams per day. 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. Your doctor prescribed Fentanyl 50 mcg/hour patch (15 patches per 30 days) to treat pain. The Medicare approved compendia does support the use of this drug for your condition.  The documentation provided does not support the excess quantity requested.Initially the prescriber requested a morphine milligram equivalent dose of 200 mg/day.  On 2/17/2021, the prescriber requested a morphine milligram equivalent dose of 400 mg/day.  On 2/24/2021, the prescriber changed the request to a morphine milligram equivalent dose of 1000 mg/day. A form submitted on 2/21/2021 has an unsigned cross off of a morphine milligram equivalent dose of 900 mg/day.  The prescriber was asked to submit medical records with the Reconsideration appeal to support the appeal.  No medical records were submitted.  Without supporting records there are serious safety concerns.  Therefore, an exception to the plans coverage criteria is not supported.   Our Physician Reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Repatha 140 milligrams per milliliter injection pen prescribed for high cholesterol. The Part D plan denied your request for a tiering exception because Repatha is a brand name Tier 3 drug and there are no drugs on lower cost-sharing tiers to treat 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. We also researched Medicare systems and reviewed the enrollment data available. The record shows Repatha is being prescribed for high cholesterol. The Medicare approved compendium, supports the use of the requested drug for your condition. The plan shows Repatha is a brand name Tier 3 drug. There are no drugs on lower cost-sharing tiers to treat your condition. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine HCl 5 milligram tablets prescribed for skeletal muscle spasm. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Cyclobenzaprine HCl for skeletal muscle spasm. You have been on this medication long-term and your prescriber has indicated the muscle spasm is not related to an acute musculoskeletal condition. 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

You requested off-formulary Livalo two milligrams prescribed daily for hypercholesterolemia. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. The prescriber states you have tried pravastatin and atorvastatin in the past.  The prescriber has not indicated 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 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 Hydrocodone bitartrate/Acetaminophen 10-325 milligram tablets prescribed three times daily. You requested that the plan provide reimbursement for this drug. The plan did not make a decision within the required timeframe. 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. We asked your prescriber to send us information regarding your condition. We did not receive the documentation requested.No medical records were provided by the prescriber to support your need for this medication. It could not be determined whether the requested drug was being prescribed for 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 reimburse Hydrocodone bitartrate/Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Estriol powder prescribed as directed. The Part D plan denied coverage for the compounded medication because it did not contain any ingredients that met the definition of a Part D drug. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.We asked the prescriber to send us information regarding the compounded medication and the enrollees condition. We did not receive the documentation requested.The documentation shows you requested Estriol powder. Bulk powders do not satisfy the definition of a Part D drug and are not covered by Part D. The documentation available for review does not confirm the other ingredients in the compound. It could not be determined whether the requested compound medication meets the definition of a Part D drug.A physician reviewed your appeal and determined that the plan is not required to cover Estriol powder.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin ER 10 milligrams tablets to treat intractable pain due to stage IV lung adenocarcinoma. 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, specifically Xtampza ER and Morphine ER, 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

At issue is an off-formulary request for Gralise Extended Release 300 milligram tablet prescribed 2-3 times a day to treat small fiber neuropathy.  The Part D plan denied coverage because medical necessity was not established.  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 use of the requested drug to treat the provided diagnosis is an off-label use.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  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 drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Blisovi FE 1.5/30 kit prescribed for menorrhagia. 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 Blisovi FE 1.5/30 for menorrhagia. 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

You requested Calcipotriene 0.005% cream prescribed for plaque psoriasis. 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.Your medical records show your doctor prescribed Calcipotriene for plaque psoriasis. Medicare approved compendia does support the use of this drug for your condition. However, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria. The plan requires an intolerance or contraindication to topical triamcinolone 0.5% before they will cover the requested drug. 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 Calcipotriene.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxbryta 500 milligram tablet to treat sickle cell 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 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.Relevant medical records were requested but not provided. The prescriber has not indicated 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 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 Clindolipid 20% prescribed for malnutrition. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The physician submitted a supporting statement. The documentation indicates the physician had prescribed a compound which included Clindolipid 20% for the enrollees condition.However, the records do not show that the enrollee cannot take Intralipid included on the plans formulary for their condition. The physician did not indicate all alternatives on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Clindolipid 20%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is an off-formulary request for Vyvanse 20 milligram capsule prescribed for attention deficit disorder. 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 physician submitted a supporting statement and medical records. The medical records show the physician had prescribed Vyvanse to treat your attention deficit disorder. Medicare approved compendia supports the use of the requested drug for your condition.The physician states you have tried Ritalin, Strattera, and Focalin for your condition. However, there is no evidence that you have tried Dextroamphetamine-amphetamine (Adderall).  A physician reviewed your appeal and determined that the plan is not required to cover Vyvanse.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil Citrate 20 milligrams prescribed for erectile dysfunction. The Part D plan denied your request because drugs prescribed for sexual or erectile dysfunction do not meet the definition of Part D drugs. 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 determined that the plan is not required to cover Sildenafil Citrate because it was prescribed for erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ranolazine ER 1000-milligram tablets prescribed for coronary artery disease and angina. You asked the Part D plan to provide a tiering exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The records show Ranolazine ER is being prescribed for coronary artery disease and angina. The Medicare approved compendia supports the use of the requested drug for your condition. Ranolazine is a generic drug that is on your plan's formulary at tier level 3. Your doctor submitted a prescriber statement indicating that you tried Crestor, Isosorbide, Aspirin, Nitroglycerin, and Carvedilol. These drugs did not control your condition. However, the plan formulary includes other drugs that could be used to treat your condition. Your medical records do not show all alternative drugs on the plan formulary have been tried or why you cannot take them. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit. Therefore, the plan is not required to grant a tiering exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ketorolac Tromethamine 10 milligrams prescribed for fibromyalgia, chronic migraines, and chronic pain. The Part D plan denied your request stating that the provided diagnosis is not a medically accepted indication. 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.Ketorolac Tromethamine was ordered to treat the enrollees chronic pain. 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 the requested drug.