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

You requested Nurtec ODT 75 milligram tablets prescribed as directed for migraines. 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 also researched Medicare systems and reviewed the enrollment data available. 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Nurtec ODT.A physician reviewed your appeal and determined that the plan is not required to cover the Nurtec ODT.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide ER 3 milligram capsules prescribed as directed for eosinophilic colitis and irritable bowel syndrome with diarrhea. Another prior authorization was requested for allergic rhinitis. 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 also researched Medicare systems and reviewed the enrollment data available. Your records show your doctor prescribed Budesonide ER to treat your eosinophilic colitis and irritable bowel syndrome with diarrhea with an additional diagnosis of allergic rhinitis added. Medical records were not submitted to support the use of Budesonide for your condition. It cannot be determined that the drug is being used for a medically accepted indication. 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 Budesonide ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% Patch to treat chronic back pain. The Part D plan denied the request stating that the provided diagnosis is a 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.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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Emgality 120 milligram/milliliter pen prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because Emgality 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 Emgality 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 coverage for a Spiriva 1.25 microgram per actuation inhaler. 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. The Part D plan has prior authorization requirements that must be met before coverage of Spiriva is approved. During this review, a request was submitted to the prescriber to provide a diagnosis, to address the plans coverage 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 an off-formulary request for Armour Thyroid 90 milligram tablets to treat hypothyroidism. 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.Non-FDA approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Jardiance 10 milligram tablets prescribed for diabetes. The Part D plan denied your request for a tiering exception because Jardiance 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 Jardiance 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

At issue is a tiering exception request for Vyzulta 0.024 percent ophthalmic solution for 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.This drug is being 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Transderm-Scop 1.5 milligram patches to treat the diagnosis of nausea with vomiting, unspecified. 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 use of the requested drug to treat the provided diagnoses 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 conditions. 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 Transderm-Scop 1.5 milligram patches.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipratropium Bromide/Albuterol Sulfate 0.5 milligram/3 milliliter-3 milligram/3 milliliter inhalation solution. The Part D plan denied the 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 drug at issue is for use with a nebulizer in the enrollees home. This is eligible for coverage under Part B. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Ipratropium Bromide/Albuterol Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lubiprostone 24 micrograms twice daily to treat chronic idiopathic constipation. 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.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We received the documentation and included it in our review.The prescriber statement and records submitted state the enrollee had previous treatment with Lactulose and Linzess. However, an explanation as to why the medications were ineffective or caused adverse side effects was not included. The documentation does not satisfy the plans coverage criteria. 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 Nucynta 100 milligram oral tablet prescribed for chronic pain syndrome. 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. The records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Nucynta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Anoro Ellipta 62.5-25 micrograms inhaler prescribed daily for chronic obstructive pulmonary disease. 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 also researched Medicare systems and reviewed the enrollment data available. The plan requires an intolerance or contraindication to conventional therapy before they will cover the requested drug. The prescriber has not sufficiently indicated why all alternatives required by the plan would likely cause harm or not be as effective for the enrollee as 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 the Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclophosphamide 50 milligram capsules prescribed to treat amyloidosis in combination with Bortezomib and Dexamethasone.  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 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. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Perforomist 20 microgram/2 milliliters vial nebulizer. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible for a lower cost-share under the Medicare Part D Prescription Drug benefit. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The record shows your doctor prescribed the medication for chronic obstructive pulmonary disease. This drug is eligible for coverage under Medicare Part B. Medicare Part D does not cover medications used with a nebulizer.We determined that the plan is not required to cover Perforomist.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin CR tablet 80 milligram twice daily to treat chronic back pain with radiculopathy. 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 prescriber has provided medical records. However, the documentation does not address 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

You requested Neoral 25 milligram capsules prescribed daily for kidney transplant. 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 determined that the plan is not required to cover the Neoral. Medicare records indicate the enrollee received a kidney transplant covered by Medicare Part A. Therefore, the Neoral is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B is not eligible for coverage under Part D. 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 Gattex 5 milligram kit prescribed as directed for short bowel syndrome, high output ostomy, and altered bowel elimination. The Part D plan denied your request for a tiering exception.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 Testosterone Cypionate 200 milligrams/milliliter. At initial determination and redetermination no diagnosis was given. 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.At reconsideration a diagnosis of primary hypogonadism was given. No medical records were provided by the prescriber to support this diagnosis. 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Advair Diskus 500/50 microgram inhalation powder prescribed for 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. Advair Diskus is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition 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 Advair Diskus at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Octreotide Acetate Solution 50 microgram/milliliter prescribed for Crohns disease and high ileostomy output. 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 Octreotide Acetate for your 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Saxenda 18 milligram/3 milliliter pen injector for morbid obesity due to excess calories. 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 Saxenda because it was prescribed for weight loss. Drugs to treat anorexia, weight loss, or weight gain 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 a quantity limit exception for Buprenorphine Hydrochloride/Naloxone Hydrochloride 2 milligram/0.5 milligram sublingual tablets prescribed for postlaminectomy syndrome, unspecified internal derangement of right knee, and spinal stenosis. 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 Buprenorphine Hydrochloride/Naloxone Hydrochloride for postlaminectomy syndrome, unspecified internal derangement of right knee, and spinal stenosis. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed and a quantity limit exception 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 Lidocaine 5% ointment prescribed for your disorder of the autonomic nervous system, unspecified disorder of autonomic nervous system, and chemotherapy induced polyneuropathy. The Part D plan denied the request. 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 submitted documentation indicates your doctor prescribed Lidocaine 5% ointment for your 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 Lidocaine 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% Gel 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.At reconsideration diagnoses of Charot-Marie-Tooth disease and low testosterone were given. No medical records were provided by the prescriber to support these diagnoses. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria.  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 Vosevi 400/100/100 milligram tablet prescribed for your chronic Hepatitis C with decompensated cirrhosis. The Part D plan denied the request. 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 submitted documentation indicates your doctor prescribed Vosevi for your 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 Vosevi.