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

You requested Cosentyx 150 milligrams/milliliter pen injector prescribed as directed to treat plaque 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. 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 Cosentyx.A physician reviewed your appeal and determined that the plan is not required to cover the Cosentyx.
Appeal type: Prescription Drug
Decision: Favorable

You requested Restasis Multidose 0.05% Eye Drops prescribed for 55 milliliters for 30 days to treat keratoconjunctivitis sicca. 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 plan allows 5.5 milliliters per 25 days but the initial request was for 55 milliliters. The prescriber indicates that the medication is providing relief and acknowledged the plan states the enrollee can have 5.5 milliliters per 25 days and is requesting the enrollee get the maximum amount allowed. A physician reviewed your appeal and determined that the plan is required to cover 5.5 milliliters per 25 days of Restasis Eye Drops which is the maximum amount allowed.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tizanidine Hydrochloride 2 milligram oral tablet prescribed for myofascial spasms. 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 Tizanidine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Vascepa 1 gram capsules prescribed to treat the enrollees condition. The Part D plan denied the 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.Vascepa 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira 40 milligram/0.4 milliliter pen injector prescribed for the enrollees condition. 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.Humira is on the specialty tier of your plans formulary. Biologics that are on the plans specialty tier 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 Sandostatin LAR Depot 20 milligram vial prescribed one every 28 days for recurrent gastrointestinal bleeding. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia does not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Sandostatin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Flecainide Acetate 50 milligram tablets prescribed for paroxysmal atrial fibrillation. 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.Flecainide Acetate is a generic drug on Tier 3 of the plans formulary. The prescriber has not sufficiently addressed why all of the generic drugs on the lower tiers of the plans formulary to treat paroxysmal atrial fibrillation have been tried and failed, or are contraindicated. A physician reviewed your appeal and determined that the plan is not required to cover the Flecainide Acetate at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Armodafinil 200 milligram tablets. 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 Armodafinil has been prescribed to treat multiple sclerosis-related fatigue. 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 Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is First-Omeprazole Suspension 2 milligram per milliliter. 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 First-Omeprazole Suspension because it has not been approved by the Food and Drug Administration. Drugs that have not been approved by the Food and Drug Administration 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 coverage for Oxycontin ER 10 milligram tablets prescribed for chronic pain. 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.Oxycontin ER is not included your plans formulary. During this review, we requested a statement and supporting medical records from your doctor to address the alternative medications included in your plans formulary to treat your condition. Your doctor did not respond to our request.Your doctor has not sufficiently addressed why all alternative medications that are included in the plans formulary to treat your condition 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. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

You requested reimbursement for medications paid out of pocket. The request was not routed timely and not received by the appropriate department. 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. The record shows you were billed and paid for three medications including Eliquis 5 milligram oral tablets ($352.10), Dexamethasone 6 milligram oral tablets ($7.85), and Carvedilol 3.125 milligram oral tablets ($24.02).We determined that the plan is required to reimburse you for the multiple medications.
Appeal type: Prescription Drug
Decision: Favorable

You requested reimbursement for Trazodone 50 milligram tablet paid out of pocket. The request was being auto forwarded for a missed turnaround. We received an auto-forwarded 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 record shows you were billed and paid for Trazodone 50 milligram tablet ($7.03).We determined that the plan is required to reimburse you for the medication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Voltaren Gel 1 percent prescribed for pain in the left and right shoulders and pain in right and left knees. 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 Voltaren Gel for pain in the left and right shoulders and pain in right and left knees. In review of the Medicare approved compendium, pain in the left and right shoulders and pain in right and left knees are not medically accepted indications for Voltaren Gel. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Voltaren Gel at issue.
Appeal type: Prescription Drug
Decision: Favorable

You requested Dextraoamphetamine/Amphetamine 30 milligram tablets prescribed daily for fatigue related to multiple sclerosis. 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. At initial determination and redetermination the diagnosis of fatigue related to multiple sclerosis was given. At reconsideration a diagnosis of attention deficit hyperactivity disorder was given. The medical records submitted at reconsideration show you were prescribed Dextraoamphetamine/Amphetamine 30 milligram tablets daily for attention deficit hyperactivity disorder. The Medicare approved compendia do support the use of this drug as a medically accepted indication for your condition.A physician reviewed your appeal and determined that the plan is required to cover Dextraoamphetamine/Amphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mesalamine 1.2 gram tablets prescribed four times daily for the enrollees condition. 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.Mesalamine is a generic drug on Tier 4 of the plans formulary. Your doctor submitted a supporting statement. The statement 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 Methotrexate 2.5 milligram tablet prescribed as directed for frontal fibrosing alopecia. 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 record shows you were prescribed Methotrexate to treat your condition. However, the Medicare approved compendia do not support the use of this drug for your 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 Methotrexate because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz 5 milligram tablets prescribed as directed for vitiligo. 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 medical records show the doctor prescribed Xeljanz for vitiligo. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Entecavir 1 milligram tablets prescribed for chronic hepatitis B infection. 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.Entecavir is a generic drug on Tier 4 of the plans formulary. The prescriber has not sufficiently addressed why the generic drug of the same type on the lower tier of the plans formulary to treat the noted condition has been tried and failed, or is contraindicated. A physician reviewed your appeal and determined that the plan is not required to cover Entecavir at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Saxenda 18 milligram/3 milliliter pen injector prescribed daily for weight loss. The Part D plan denied your request because Medicare has excluded Part D coverage for drugs used for the treatment of weight gain or to promote weight loss. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We determined that the plan is not required to cover Saxenda because drugs used to treat weight gain (promote weight loss) 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 tiering exception for Ventolin HFA 108 (90 base) micrograms/actuation inhaler prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because Ventolin HFA 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 Ventolin HFA 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 Aimovig 70 milligrams/milliliter injection prescribed as directed for the prevention of migraines. The Part D plan denied your request for a tiering exception the drug is considered a biologic drug, and there are no biologic drugs available on a lower tier of 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. Aimovig is a biologic drug on Tier 3 of the plans formulary. There are no biologic 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 cover Aimovig.
Appeal type: Prescription Drug
Decision: Favorable

You requested reimbursement for Methocarbamol 500 milligram oral tablet paid out of pocket. The request was not routed timely and not received by the appropriate department. 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. The record shows you were billed and paid for Methocarbamol 500 milligram oral tablet ($30.14).We determined that the plan is required to reimburse you for the medication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Synthroid 75 microgram tablets prescribed for the enrollees condition. 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.Synthroid is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. 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% Ointment to treat pain related to other intervertebral disc-degeneration lumbosacral region. 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 Glycopyrrolate1 milligram tablets prescribed twice daily for urinary incontinence and fecal incontinence. 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 medical records show your doctor prescribed Glycopyrrolate to treat your urinary incontinence and fecal incontinence. However, the Medicare approved compendia do not support the use of this drug for your 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 Glycopyrrolate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Vascepa 1 gram capsules prescribed for hypertriglyceridemia in the presence of cardiovascular 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. Vascepa 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 Vascepa at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 micrograms blisters with device prescribed as needed 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 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 Anoro Ellipta.A physician reviewed your appeal and determined that the plan is not required to cover the Anoro Ellipta.