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

At issue is Tramadol Hydrochloride Extended Release 200 milligram tablets to treat pain. A quantity of 60 tablets for 60 days. 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 plans quantity limit for the requested drug is a 30 day supply. In addition, the progress notes included indicate that the physician is changing the enrollees medication regimen of the requested drug. As such, an exception to the quantity limit requirements cannot be granted.A physician reviewed your appeal and determined that the plan is not required to cover Tramadol Hydrochloride Extended Release at 60 tablets for 60 days.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Amiovig 140 milligrams milliliter injection to treat migraine headaches. 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 plan requires for continuation of Amiovig that the enrollee experience a reduction in migraine days per month. The documentation includes clinical notes which satisfied the plan's coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humalog 100 units/milliliter prescribed for type 2 diabetes mellitus. 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 for information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested.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 Humalog 100 units/milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 49/51 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Entresto is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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 a tiering exception request for Tadalafil to treat your benign prostatic hyperplasia. The Part D plan denied the request. We received a reconsideration 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.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.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 Travatan Z 0.004% eye drops. 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 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.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 Xarelto 15 milligram tablets prescribed as directed for persistent atrial fibrillation. The Part D plan denied your 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. Xarelto is a brand drug on Tier 2 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 condtiion. 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 Calcitriol 0.25 microgram capsule prescribed as directed for hyperparathyroidism. 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 records submitted at the reconsideration level. The prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked to confirm that the enrollee was no longer receiving dialysis. We have received a response and have included in our review.No medical records were submitted to confirm a diagnosis. Based upon the current record, 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 cover Calcitriol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz 5 milligram tablets prescribed daily for lichen planopilaris. 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 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 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 Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Octreotide Acetate solution 100 microgram/milliliter prescribed for gastrointestinal hemorrhage unspecified. 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 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 your appeal and determined that the plan is not required to cover the Octreotide Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin 80 milligram oral tablet prescribed for pain. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 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.Your physician submitted a supporting statement. The supporting statement shows Oxycontin was prescribed to treat low back pain, knee pain, and foot pain due to fibromyalgia. However, the records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. The prescriber has not provided patient specific clinical rationale, with supporting medical documentation, to indicate that all alternatives required by the plan have been tried and failed, or why the preferred drug would likely not be as effective as the requested drug. A physician reviewed your appeal and determined that the plan is not required to cover Oxycontin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Motegrity 2 milligram 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 physician submitted a supporting statement. The prescriber statement indicates that Motegrity is prescribed to treat chronic idiopathic constipation.However, medical records have been submitted for review and support opioid-dependent constipation. The Medicare approved compendia do not support the use of this specific drug for this specific condition.A physician reviewed your appeal and determined that the plan is not required to cover Motegrity.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carvedilol 40 milligram extended-release oral capsule. We received an auto-forwarded reconsideration request from the coverage level.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 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 tiers would not work for you. . However, we did not receive the documentation.Carvedilol is a generic drug on Tier 4 of the plans formulary. The prescriber has not provided patient specific clinical rationale, with supporting medical documentation, to indicate that all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Entresto 24/26 milligram tablets prescribed for chronic heart failure and an ejection fraction of 17 percent. The Part D plan denied your request for a tiering exception because Entresto 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 Entresto 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 Nexium DR 40 milligram capsule prescribed as directed to treat acid reflux. 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 record shows that your doctor prescribed Nexium DR to treat your condition. There are no medical records to support all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Nexium DR.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Intravenous Immunoglobulin 10% solution 35 grams daily for 5 days every month. 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 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 indicates that Intravenous Immunoglobulin has been prescribed to treat small fiber neuropathy. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover Intravenous Immunoglobulin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Lidocaine 5 percent patch prescribed daily for pain post fall. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Lidocaine for pain post fall. In review of the Medicare approved compendium, pain post fall is not a medically accepted indication for Lidocaine as prescribed. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Lidocaine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cosentyx 300 milligram pen injector to treat psoriasis vulgaris. 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 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 Azopt 1% solution prescribed three time daily for glaucoma. 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.  Azopt is a brand drug on Tier 3 of the plans formulary. Azopt is a carbonic anhydrase inhibitor. 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 Aripiprazole 1 milligram/milliliter solution prescribed for chronic fatigue syndrome and immune dysfunction. The Part D plan denied your 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Dofetilide 125 microgram capsules prescribed for persistent atrial fibrillation. The Part D 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. Dofetilide is a generic drug included on Tier 1 of the plans formulary. Tier 1 is the lowest tier on the formulary. Therefore, the Dofetilide is already being covered at the lowest cost-sharing tier available and is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Dofetilide at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Spiriva HandiHaler 18 microgram capsules for oral inhalation 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. We asked the prescriber to send us medical records and a supporting statement showing the medical necessity of Spiriva. However, we did not receive the documentation.The available documentation does not contain medical records. 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 cover the Spiriva HandiHaler.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zileuton 600 milligram tablets prescribed twice daily for systemic mastocytosis. 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 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 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 Zileuton.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vascepa 1000 milligram prescribed daily for your mixed hyperlipidemia with a triglyceride level over 250. The Part D plan denied the request stating that the provided diagnosis is a non-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 records submitted at the reconsideration level. The prescriber states the enrollee has a triglyceride level over 250 and has hypertension.  Relevant medical records were requested but not provided. 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 requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Diphtheria-Tetanus Vaccine. 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 reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.Diphtheria-Tetanus Vaccine is a generic drug on Tier 3 of the plans formulary. There are no generic 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 Lidocaine 5% patch to treat fibromyalgia and chronic back pain. 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 use of the requested drug to treat the provided diagnosis is an off-label use. Relevant medical records were requested and were not provided.  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.