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

You requested Methylphenidate Hydrochloride 10 milligram tablets prescribed for progressive supranuclear palsy. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates your doctor prescribed Methylphenidate Hydrochloride for progressive supranuclear palsy. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As it cannot be determined that the drug was 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: Favorable

You requested Mektovi 15 milligram tablets prescribed as directed for metastatic melanoma. 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 Mektovi, in combination with Braftovi, to treat metastatic melanoma. The enrollee was found to have a nasal melanoma with BRAF mutation. The enrollee was treated with Keytruda, but had frank progression of the disease after four cycles of treatment. The enrollee developed new lesions on the back and liver, as well as possible bony lesions. Additionally, the enrollee developed new gum lesions and the nasal lesion was enlarging. Since Keytruda was not beneficial for this enrollee, the physicians treatment plan includes discontinuation of Keytruda. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Binimetinib, in combination with Encorafenib, is indicated in adults to treat unresectable or metastatic melanoma with a BRAF V600E or V 600K mutation. Furthermore, the documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Mektovi.
Appeal type: Prescription Drug
Decision: Partially Favorable

You requested Tretinoin 10 milligram oral capsules prescribed at a dosage of 45 milligrams per square meter as directed for acute promyelocytic leukemia. The Part D plan denied your request for a 98-day supply of medication. 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 medical records show the doctor prescribed Tretinoin to treat acute promyelocytic leukemia. The record shows the enrollee has received induction therapy with Tretinoin and arsenic. The enrollee has now been prescribed consolidation therapy with Tretinoin and arsenic. The Medicare approved compendium support the use of the requested drug to treat the enrollees condition. The prescriber requested a 98-day supply of Tretinoin to provide four cycles of consolidation therapy with Tretinoin. The plan is required to cover a 90-day-supply of Tretinoin. However, the plan is not required to cover the remaining 8-day supply of Tretinoin because the documentation does not support the medical necessity of exceeding the 90-day supply limit. A physician reviewed your appeal and determined that the plan is required to cover a 90-day supply of Tretinoin. The plan is not required to cover the remaining 8-day supply of Tretinoin.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Febuxostat 80 milligram tablet prescribed daily for hyperuricemia in gout. 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 records submitted at the reconsideration level.The medical records show the doctor prescribed Febuxostat to treat your hyperuricemia in gout. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the drug is allowed for your diagnosis and the medical records state the alternative drug Allopurinol causes you to have nose bleeds. The documentation provided shows the plan's coverage criteria have been satisfied.A physician reviewed your appeal and determined that the plan is required to cover Febuxostat.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablet for anticoagulation in an enrollee with deep venous thrombosis. 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. Eliquis 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 Entresto 49-51 milligram tablets. 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. Entresto 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 Candesartan Cilexetil 8 milligram tablets.We received the case to perform 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 requested the prescriber information from the enrollee to request additional information but did not get a response. The documentation was insufficient to determine if the drug was medically indicated for the enrollee.A physician reviewed your appeal and determined that the plan is not required to cover Candesartan Cilexetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablet prescribed twice daily for small intestinal bacterial overgrowth. 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 shows your doctor prescribed Xifaxan to treat your small intestinal bacterial overgrowth. However, the 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Daypro 600 milligram tablet prescribed twice daily for your condition. 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.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 this medication and why other medications on the plan's formulary would not work for you. We did not receive the documentation requested.Medicare rules state that for prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must be for treatment of a condition that is completely unrelated to the terminal condition(s) or related conditions for which hospice coverage is being provided. The enrollment data shows that hospice coverage was terminated on March 1, 2021. However, no medical records were provided by the prescriber to support a 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 Daypro.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Omega-3-Acid Ethyl Esters 1 gram capsules prescribed for hyperlipidemia, unspecified. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The records show your physician prescribed Omega-3-Acid Ethyl Esters 1 gram capsules to treat hyperlipidemia, unspecified. 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 Omega-3-Acid Ethyl Esters 1 gram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zolpidem Tartrate 10 milligram tablets. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not contain medical records or evidence of a prescribed diagnosis. As it cannot be determined that the drug was 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 a request for coverage of Donnatal 2 gram tablets prescribed for irritable bowel syndrome. The Part D plan denied the request for coverage.  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. Donnatal is not included in the plans formulary. During this review, supporting medical records were requested from the prescriber to address why the alternative medications that are included in the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. However, the prescriber did not respond to the request. 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

At issue is Propranolol 60 milligram extended-release oral capsule prescribed daily. 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. Propranolol is a generic drug on Tier 4 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers to treat the enrollees condition of migraine headaches. 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 Uceris 2 milligram Actuation Foam prescribed twice daily for two weeks and once daily for four weeks for active, mild to moderate distal 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. 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. However, we did not receive the documentation.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, medical records have not been submitted to support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Uceris.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 97 milligram-103 milligram tablets prescribed as directed. 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. Entresto 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 Farxiga 10 milligram tablets prescribed as directed. 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. Farxiga 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 Myrbetriq ER 25 milligram tablets prescribed daily. 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. Myrbetriq ER is a brand drug on Tier 4 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: Favorable

You requested Sirolimus 0.5 milligram tablets prescribed for an enrollee who received a kidney transplant. The Part D plan denied the request. We received the case to perform 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. The enrollee was not covered under Medicare when they received the kidney transplant. Therefore, this drug is eligible for coverage under Part D benefits. Medicare approved compendia support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is required to cover Sirolimus.
Appeal type: Prescription Drug
Decision: Favorable

You requested Dupixent 300 milligram/2-milliliter syringe prescribed for bullous pemphigoid. The Part D plan denied the request as 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 information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia.At reconsideration, Dupixent 300 milligram/2-milliliter syringe was prescribed for bullous pemphigoid. The Medicare approved compendia, and the FDA, list this drug as an orphan drug for the medical condition in this enrollee. Therefore, it is considered a medically accepted indication.This drug is on the plans formulary. The documentation, however, does not satisfy the plans prior authorization criteria. However, the enrollee has used this medication successfully; an exception to the prior authorization criteria is granted. Our physician reviewer's opinion is that the plan should cover this drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Chantix 1 milligram tablets. The Part D plan denied coverage because medical necessity for the medication could not be established with the submitted documentation.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 part D plans prior authorization requirement for coverage of Chantix is that it is prescribed for any Food and Drug Administration-approved indication. The prescriber statement and medical records submitted at reconsideration indicate that Chantix has been prescribed to the enrollee to aid in smoking cessation. The prescriber notes that the enrollee has decreased smoking from 10 to 2 cigarettes a day. Smoking cessation assistance is a Food and Drug Administration-approved indication for the use of Chantix and a medically-accepted indication per the Medicare compendia. Therefore, the medical records submitted at reconsideration show that the prior authorization requirement for coverage of the medication has been satisfied and that the medication is being used for a covered indication. A physician reviewed the appeal and determined that the plan is required to cover the Chantix.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 200 milligram/1.14-milliliter syringe prescribed every 14 days for asthma. 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 records submitted at the reconsideration level. Your medical records show your doctor prescribed Dupixent to treat your asthma. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Dupixent. There is no evidence of eosinophilic phenotype, defined by an elevate peripheral blood eosinophil level of greater than or equal to 150 cell/uL at therapy initiation or greater than or equal to 300 cells/uL in the previous 12 months OR has oral corticosteroid-dependent asthma; AND has been unable to achieve adequate control of asthma while on maximum tolerated inhaled corticosteroid therapy in combination with a long acting beta agonist. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Tadalafil 5 milligram tablets prescribed for benign prostatic hyperplasia. The Part D plan denied the request for coverage.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 does not satisfy the plans coverage criteria for this medication. 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate Hydrochloride 5 milligram tablets prescribed as directed for Guillain-Barre syndrome and Parkinsons 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. The documentation shows your doctor prescribed Methylphenidate Hydrochloride to treat symptoms related to your diagnosis of Guillain-Barre syndrome and Parkinsons disease. However, the 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 Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Bystolic 20 milligram 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.Bystolic is a brand drug on Tier 4 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.