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

At issue is Oxycontin 20 milligram tablets prescribed for severe bilateral low back pain and sciatica. The Part D plan denied coverage because insufficient documentation was provided. 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. 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 your appeal and determined that the plan is not required to cover Oxycontin.
Appeal type: Prescription Drug
Decision: Favorable

You requested Leflunomide 20 milligram tablets prescribed for treatment of a BK virus infection following a kidney transplant. 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 Leflunomide for the treatment of a BK virus infection following a kidney transplant. The Medicare approved compendia support the orphan drug designation of Leflunomide for the prevention of acute and chronic rejection in patients who have received solid organ transplants. A kidney transplant is a solid organ transplant. BK viral infection is included in this orphan drug status as a cause of rejection, which is lessened with Leflunomide use. A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Topiramate ER 150 mg capsule for migraine prophylaxis.   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 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 Lidocaine 5% patch prescribed for back pain secondary to a sacral fracture. 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 Lidocaine patch for the treatment of back pain secondary to a sacral fracture. 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

At issue is Anoro Ellipta 62.5-25 microgram inhaler for chronic obstructive pulmonary disease. 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 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 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

Clomiphene Citrate 50 milligram was requested for an unknown diagnosis.  The appeal was untimely and the appeal was forwarded to the qualified independent contractor.  As well, the requested drug is not on the Plans formulary.  We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis, to address the nonformulary exception 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 Cyclobenzaprine five milligram tablet to treat calcium pyrophosphate deposition arthropathy. Medical records from date of service February 24, 2021, support this diagnosis. 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 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

At issue is Lidocaine 5% ointment to treat shingles with pain, scratching, and itching. 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 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, in this formulation, 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

At issue is Tramadol ER 200 milligrams every 12 hours to treat chronic pain. 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. 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 Tramadol ER 200 milligrams. A physician reviewed your appeal and determined that the plan is not required to cover Tramadol ER 200 milligrams because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brimonidine Tartrate 0.15% ophthalmic solution 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.Brimonidine Tartrate is a branded generic drug on Tier 3 of the plans formulary. Your doctor submitted a supporting statement. The statement doctor did not address why all alternative lower-tier medication on the plans formulary would not work for you. All generic drugs on lower tiers have not been tried. 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 Bystolic 10 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other drugs on a lower cost-sharing tier. 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.Bystolic is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Valacyclovir 1000 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the prescriber did not address all alternatives were tried and failed. 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.Valacyclovir is a generic drug on Tier 3 of the plans formulary. We requested a supporting statement from your doctor to address why all alternative lower-tier medication on the plans formulary would not work for you. The statement was not submitted. The documentation does not support all generic drugs on lower tiers have not been tried. 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 Oxycodone Hydrochloride 10 milligrams every 12 hours to treat severe back pain. 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. 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 Oxycodone Hydrochloride 10 milligrams. A physician reviewed your appeal and determined that the plan is not required to cover Oxycodone Hydrochloride 10 milligrams because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dextroamphetamine/Amphetamine 10 milligram tablets prescribed for idiopathic hypersomina. 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 Dextroamphetamine/Amphetamine for idiopathic hypersomnia. 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 Sunosi 150 milligram tablets prescribed daily for excessive daytime sleepiness due to multiple sclerosis. The Part D plan denied your request because the Food and Drug Administration has not approved this drug for your diagnosis. 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.Your medical records show your doctor prescribed Sunosi to treat your excessive daytime sleepiness due to multiple sclerosis. 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 the enrollees 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 Sunosi. A Part D drug must be prescribed for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bupropion HCL 100 milligram sustained release tablet prescribed as directed for depression. The Part D plan denied your request for a tiering exception because there were no generic drugs of the same type on the lower cost sharing tiers. 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.Bupropion HCL 100 milligram sustained release tablet 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.  Also note that medical records were requested and were not provided.  Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hizentra seven grams weekly to treat non-familial hypogammaglobulinemia.  The Part D plan denied the request stating that the provided diagnosis is a non-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 use of the requested drug to treat the provided diagnosis is a medically accepted indication.  The Medicare approved compendia does contain citations to support the use of the requested drug, as prescribed, for the treatment of conditions that are primary hypogammaglobulinemias.  However, medical record documentation submitted, supports the enrollee's condition as acquired, not primary, hypogammaglobulinemia. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus prescribed daily following a kidney transplant that was performed on November 5, 1999. The Part D plan denied your request to cover the medication under Part D. 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 other information submitted at the reconsideration level.The record shows that your doctor prescribed Tacrolimus as an immunosuppressive drug following your kidney transplant. Medicare records indicate you were covered under Part A at the time of your transplant. Therefore, Tacrolimus is covered under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law. As such, our decision is that the Part D plan is not required to cover Tacrolimus. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit. In addition, the request for a tiering exception for Tacrolimus was not reviewed. We cannot consider a tiering exception for a drug for which the Part D Plan is unable to provide coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colistimethate sodium 150 milligrams prescribed for use with a nebulizer to treat Pseudomonas aeruginosa infection in an enrollee with cystic fibrosis. The Part D plan denied coverage because the prior authorization criteria were not met. 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 documentation shows the enrollee will administer Colistimethate sodium via nebulizer. 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 Colistimethate sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Enoxaparin Sodium 120 milligrams per 0.8 milliliters, 24 milliliters/30 days, to be given subcutaneously daily due to the enrollees history of pulmonary embolism. The Part D plan denied your request because the plan's formulary allows a maximum quantity of 22.4 milliliters per claim (28 days) for this 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 information submitted at the reconsideration level. The submitted prescriber statement indicates that the enrollee requires 120 milligrams per 0.8 milliliters daily, which would be 24.0 milliliters for a 30-day supply. This exceeds the plan's quantity limit of 22.4 millilters for a 28-day supply. The plans quantity limit criteria are not satisfied for the continued request for a 30 day supply. If the prescriber were to order a 28 day supply, which would be 22.4 milliliters, the quantity limit would be met.A physician reviewed your appeal and determined that the plan is not required to cover the Enoxaparin Sodium above the quantity limit of 22.4 millilters per claim, which is a 28 day period.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temazepam 30 milligram capsules prescribed for insomnia. The Part D plan denied coverage because the prior authorization criteria were not met. 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 statement does not show that the enrollee has tried or is unable to try a non-high risk medication alternative 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 Temazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Raloxifene HCL 60 milligram tablets prescribed daily for osteoporosis. 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. Raloxifene HCL is a generic drug on Tier 3 of the plans formulary. The doctor submitted a supporting statement indicating drug is being used for treatment of both osteoporosis and to reduce risk of breast cancer, which are both medically accepted indications. There are no drugs on the lower tiers, of the same type, to treat both these conditions. 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 Clobazam 10 milligram tablets prescribed daily for Lennox-Gastaut syndrome  seizure, adjunct. The Part D plan denied your request for 90 tablets but allowed for 60 tablets per 30 days. 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 documentation received indicates your doctor prescribed Clobazam to treat Lennox-Gastaut syndrome  seizure, adjunct. The prescriber statement confirms this diagnosis. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover the requested quantity of 90 tablets of Clobazam per 30 days.A physician reviewed your appeal and determined that the plan is not required to cover the 90 tablets of Clobazam, as the drug exceeds the number of doses that may be dispensed during a specific period of time.