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

At issue is Mesalamine ER 0.375 capsule to treat microscopic colitis. 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 a tiering exception request for Dilantin 100 milligram capsules to treat the enrollees condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Dilantin is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablets to treat chronic angina. 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.Corlanor is a brand drug on Tier 4 of the plans formulary. The prescriber has not indicated why all other 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, 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 Rocklatan 0.02-0.005% solution to treat open-angle glaucoma.   The Part D plan denied the request.  The requested drug is not on the plans formulary. 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.Rocklatan is not on the plans formulary.  Rhopressa and Latanoprost are on the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to 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

At issue is Oxycodone Hydrochloride Extended Release 10-milligram tablets to treat chronic pain. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 provided patient specific clinical rationale, supported by medical records, as to 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 Anoro Ellipta 62.5-25 micrograms/actuation inhaler 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. At initial determination and redetermination, a diagnosis of shortness of breath was given. At reconsideration, a diagnosis of chronic obstructive pulmonary disease 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 your appeal and determined that the plan is not required to cover Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cresemba 186 milligram capsules prescribed as directed for histoplasmosis. 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 record shows the physician prescribed Cresemba for the treatment of histoplasmosis. 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 Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sodium citrate-citric acid 500/334 milligram/5 milliliter solution prescribed for nephrolithiasis. The Part D plan denied your requestWe 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. According to Medicare rules, over-the-counter drugs and vitamin/mineral supplements are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover Sodium citrate-citric acid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Symbicort 160/4.5 microgram inhaler for pulmonary fibrosis. The Part D plan denied your request for a tiering exception because Symbicort 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 Symbicort 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

You requested Lubiprostone 24 microgram capsule prescribed twice daily for chronic constipation (K59.00). The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The records show you prescribed Lubiprostone 24 microgram capsule to treat the enrollees chronic constipation. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Lubiprostone 24 microgram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligram/milliliter auto-injector prescribed for atherosclerotic heart disease of native coronary artery without angina pectoris. 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. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Dextroamphetamine-Amphetamine ER 5 milligram capsules prescribed for attention deficit hyperactivity disorder. 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. Dextroamphetamine-Amphetamine ER is not included in the Part D plans formulary. The prescriber has not sufficiently addressed why all alternative drugs included in the plan to treat this condition have been tried and failed or would likely not be as effective as the requested drug or would likely cause adverse reactions or other harm. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Trihexyphenidyl hydrochloride 2 milligram tablets 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 available. At redetermination, a diagnosis of blepharospasm was given. At reconsideration, a diagnosis of ocular dystonia was given. No medical records were provided by the prescriber to support the enrollees 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 your appeal and determined that the plan is not required to cover Trihexyphenidyl hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mesalamine 1.2 grain tablets to treat ulcerative colitis. 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.Mesalamine is a generic drug on Tier 1 of the plans formulary. Tier 1 drugs are not eligible for a tiering exception because they are already classified as the lowest tier on the plans formulary. 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 Opium 10 milligram/milliliter prescribed to treat chronic diarrhea. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. This drug is not listed as a Food and Drug Administration approved drug. Therefore, it is excluded from Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Opium.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Armodafinil 150 milligram tablets prescribed daily for multiple sclerosis. 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 Armodafinil for multiple sclerosis. In review of the Medicare approved compendium, multiple sclerosis is not a medically accepted indication for Armodafinil as prescribed. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Armodafinil at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec ODT 75 milligram tablets prescribed for migraine headaches. 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. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Nurtec ODT.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Fasenra 30 milligram/milliliter Auto Injector prescribed to treat Churg-Strauss syndrome. The Part D plan denied your request for a formulary 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. Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Fasenra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gamunex-C 5 grams/50 milliliters prescribed for myasthenia gravis. 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 record shows the intravenous immunoglobulin is to be administered by a healthcare professional at an infusion center. The plan has correctly allowed coverage under Medicare Part B.We determined that the plan is not required to cover Gamunex-C 5 grams/50 milliliters under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Dexilant 60 milligram capsules prescribed for gastroesophageal reflux disease and peptic ulcer 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. Dexilant is not included in the Part D plans formulary. The prescriber has not sufficiently addressed why all alternative drugs included in the plan to treat the noted conditions have been tried and failed or would likely not be as effective as the requested drug or would likely cause adverse reactions or other harm. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trospium Chloride to treat overactive bladder. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 patient specific clinical rationale and medical records. However, the documentation does not sufficiently 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

At issue is a tiering exception request for Flecainide Acetate 50 milligram tablet to treat the enrollees condition. 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 the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.Flecainide Acetate 50 milligram tablet is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xerava 50 milligram intravenously, every 12 hours. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Xerava is prescribed to treat sacral osteomyelitis. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s).A physician reviewed your appeal and determined that the plan is not required to Xerava.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Quinine Sulfate 324 mg capsule prescribed for lower extremity cramping. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The records show you prescribed Quinine Sulfate 324 mg capsule to treat the enrollees lower extremity cramping. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Quinine Sulfate 324 mg capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Brovana 15 microgram solution prescribed twice daily for asthma/chronic obstructive pulmonary disease overlap syndrome. The Part D plan denied the 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. The record shows Brovana was prescribed to treat asthma/chronic obstructive pulmonary disease overlap syndrome. The requested drug is being used via nebulizer at home. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Therefore, coverage under Part D is excluded for any drug for which payment would be available under Part B.We determined that the plan is not required to cover Budesonide. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vumerity DR 231 milligram capsules prescribed daily for 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. 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 Vumerity DR.A physician reviewed your appeal and  determined that the plan is not required to cover the Vumerity DR.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil citrate 20 milligram tablets prescribed as directed for male erectile dysfunction. 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 record shows the physician prescribed Sildenafil citrate for male erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction 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.We determined that the plan is not required to cover the Sildenafil citrate.
Appeal type: Prescription Drug
Decision: Favorable

You requested Budesonide EC 3 milligram capsules prescribed as directed for eosinophilic esophagitis. 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 record shows the physician prescribed Budesonide EC for an enrollee with eosinophilic esophagitis, eosinophilic gastritis, and eosinophilic gastritis. The Medicare approved compendium shows orphan drug designation has been granted for Budesonide in the treatment of eosinophilic esophagitis. As such, the Medicare approved compendium does support the off-label use of this drug for the enrollees condition. An exception to the plans prior authorization criteria is medically necessary for this enrollee. A physician reviewed your appeal and determined that the plan is required to cover the Budesonide EC.