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

You requested BMX (diphenhyd/maalox/xylocaine) suspension. 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. 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 this medication. We did not receive the documentation requested.The documentation shows valid proof of payment. However, there was no diagnosis provided. In addition, no medical records were submitted for review. Therefore, it cannot be determined if the requested compound drug was prescribed for a medically accepted indication supported by the Medicare approved compendia. As such, the requested drug is not eligible for coverage under the Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover BMX (diphenhyd/maalox/xylocaine) suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Esbriet 267 milligram tablets to treat an enrollee with pulmonary fibrosis and known environmental exposure to asbestos.   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.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  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 Tremfya 100 milligram/milliliter injector prescribed every 28 days for psoriasis. 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 documentation does not 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 Tremfya.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Azelastine 0.1% (137microgram) nasal spray prescribed for rhinitis. 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. Azelastine is a generic drug on Tier 3 of the plans formulary. The prescriber has not addressed why all of the generic drugs of the same type on the lower tiers of the plans formulary to treat the noted condition have been tried and failed, or are contraindicated. A physician reviewed the appeal and determined that the plan is not required to cover the Azelastine at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Neupro 3 milligram/24-hour patch prescribed for Parkinsons disease and restless leg syndrome. 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 would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Neupro 3 milligram/24-hour patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Entresto 24-25 mg tablets prescribed to take one and a half tablets by mouth, twice a day to treat heart failure. 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 a longer recurring supply for the medication. We did not receive the requested documentation.Your medical records show your doctor prescribed Entresto 24-25 mg tablets to treat your condition. The plan has already allowed the requested drug as a recurring 90-day supply, which is the maximum allowed. A longer recurring supply cannot be allowed. The medical records do not support why an exception to the plans quantity limit is medically necessary.A physician reviewed your appeal and determined that the plan is not required to cover the Entresto 24-25 mg tablets for a longer recurring supply of 90-days.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dextroamphetamine Sulfate ER 15 milligram capsule. The Part D plan denied your request for a tiering exception.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 were unable to reach your prescriber regarding a supporting statement to show why Dextroamphetamine Sulfate ER 15 milligram capsule is medically necessary. Dextroamphetamine Sulfate ER 15 milligram capsule is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why 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 Valium 10 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. 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 Colesevelam 625 milligram tablets prescribed four times daily for irritable bowel syndrome with diarrhea. 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 indicates your doctor prescribed Colesevelam for irritable bowel syndrome with diarrhea. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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

You requested Jevity 1.5 calorie liquid supplement prescribed for dysphagia. 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.We determined that the plan is not required to cover Jevity. This item is eligible for coverage under Part B. 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 a tiering exception request for Entresto 24-milligram-26-milligram tablet 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 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.Entresto 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol sulfate 2.5 milligrams per 3 milliliters vial for nebulization prescribed to treat chronic obstructive pulmonary disease. 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.The documentation indicates that Albuterol sulfate is being administered at home via a nebulizer. Based on the information provided, we have determined the requested drug is not eligible for Medicare Part D coverage, but may be covered under Part B benefits.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lupron Depot 45 milligram (6 month) kit prescribed for malignant neoplasm of the prostate. 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. 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. However, we did not receive the documentation.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 would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Lupron Depot.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dicyclomine Hydrochloride 20-milligram tablet to treat ulcerative colitis, peptic ulcer, diverticulosis, and gastroesophageal reflux disease. The Part D plan denied the request stating that the provided diagnoses are non-medically accepted indications. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Belbuca 75 microgram film prescribed twice daily. 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 levelWe asked your prescriber to send us information about 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 similar medications on the lower teirs would not work for you. . However, we did not receive the documentation.. Belbuca is a brand drug on Tier 4 of the plans formulary. Your doctor did not address why 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

You requested Entresto 24-26 milligram tablet prescribed for non-ischemic cardiomyopathy, New York Heart Association Class II, Stage C. 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 records show you prescribed Entresto 24-26 milligram tablet to treat the enrollees non-ischemic cardiomyopathy. 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 Entresto 24-26 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vascepa 1 gram capsule for hypercholesterolemia. 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 Vascepa 1 gram capsule for hypercholesterolemia. 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 Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armour Thyroid 60 milligram tablets prescribed for hypothyroidism. 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.The drug at issue is not Food and Drug Administration approved. 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: Favorable

At issue is Zolpidem Tartrate 10 milligram tablet prescribed for insomnia. 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 records submitted at the reconsideration level. Your medical records show your doctor prescribed Zolpidem Tartrate to treat your insomnia. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided supports the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Zolpidem Tartrate. The preferred drug is contraindicated for you. Therefore, an exception to the plans prior authorization requirements can be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Voriconazole 200 milligram oral tablet. 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 Voriconazole to treat your pulmonary coccidioidomycosis unspecified. 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 Voriconazole.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue Gattex prescribed daily for short bowel syndrome and need for parenteral support. 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 records submitted at the reconsideration level. Your medical records show your doctor prescribed Gattex to treat your condition. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided supports the enrollee has not satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Gattex. There must be a documented actual change in the volume of parenteral support from before starting the drug. Therefore, an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Januvia 100 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. Januvia 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

At issue is Clobazam 10 milligram tablets prescribed to treat partial symptomatic epilepsy with complex partial seizures, intractable, without 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your prescriber indicates that Clobazam is prescribed for partial symptomatic epilepsy with complex partial seizures, intractable, without status epilepticus. However, 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 Clobazam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stendra 200 milligram tablet to treat erectile dysfunction. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is FDA approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxybutynin Chloride ER 10 milligram tablet prescribed for functional urinary incontinence. 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. Oxybutynin Chloride ER 10 milligram tablet is a generic drug on Tier 3 of the plans formulary. Your doctor did not address why 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 a request for coverage of Xiaflex 0.9 milligram reconstituted injection solution prescribed for Peyronie's disease. 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.Xiaflex is not included in the plans formulary. The prescriber has not sufficiently addressed why the alternative medications that are included in the plan to treat the noted 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 Pennsaid Solution 2% prescribed for pain in the right hip and pain in the right arm. 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. Your prescriber indicates that you have arthritis. However, Medicare compendia states the 2% Pennsaid Solution is indicated for osteoarthritis of the knee. 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 Pennsaid Solution.