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

At issue is Hetlioz 20-milligram capsule to treat Non-24-Hour Sleep-Wake Disorder (Non-24). The plan denied the request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber provided no medical records. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% patch prescribed to treat low back 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.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, the medical records do not 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 Diclofenac Epolamine 1.3% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis Emulsion 0.05% prescribed for ocular surface irregularity and significant tear insufficiency. 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. 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 Restasis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligram ER tablet prescribed to treat the enrollees 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. Myrbetriq 50 milligram ER tablet 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: Unfavorable

At issue is a request for reimbursement for Loperamide 2 milligram tablets. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. Drugs prescribed that are available over the counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.We determined that the plan is not required to cover Loperamide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brilinta 90 milligram tablets prescribed twice daily to reduce the risk of stent 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. We also researched Medicare systems and reviewed the enrollment data available. Brilinta 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: Unfavorable

At issue is Farxiga 10 milligram tablet, a quantity of 30 tablets per 30 days. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. 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 Farxiga.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 10 milligram capsule prescribed for unspecified nausea and vomiting. 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 Dronabinol 10 milligram capsule to treat your unspecified nausea and vomiting. 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 Dronabinol 10 milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 2 milligram sublingual tablet prescribed three times daily for low back pain. 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 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 shows the doctor prescribed Buprenorphine Hydrochloride sublingual tablet to treat your low back pain. However, the Medicare approved compendia do not support the use of this form of the drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram capsules prescribed twice daily for anorexia, kidney transplant status, and interstitial pulmonary disease, 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Dronabinol to treat your anorexia, kidney transplant status, and interstitial pulmonary disease, unspecified. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Divigel 0.5 milligram per 0.5 gram gel to treat the enrollees 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 asked the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the requested 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, the medical records do not 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 Divigel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tibsovo 25 milligram tablet for acute myeloid leukemia. 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 Tibsovo was prescribed to treat acute myeloid leukemia. However, the Medicare approved compendia and journal articles 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 Tibsovo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolipidem Tartrate 10 milligram tablets prescribed for insomnia. 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. We asked your doctor to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.Your doctor indicated Zolipidem Tartrate was prescribed for insomnia. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. However, the documentation provided does not show that the plans coverage criteria were satisfied.A physician reviewed your appeal and determined that the plan is not required to Zolipidem Tartrate. 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 Hizentra 10 grams per 50 milliliter solution prescribed every week for primary immunodeficiency and chronic inflammatory demyelinating polyneuropathy. 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.This drug is not eligible for coverage under Medicare Part B because the prescriber states you are unable to tolerate the intravenous form of this drug. Hizentra is not on the plans formulary. 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, the medical records do not support why other drugs on the plans formulary would not work for you. Gamunex-C is a formulary alternative that can be given subcutaneously. The prescriber states you have not tried this alternative.A physician reviewed your appeal and determined that the plan is not required to cover Hizentra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram tablet prescribed daily for non 24-hour sleep/wake cycle. The Part D plan denied the request.To make our decision, we read the documentation submitted. This includes any records submitted at the reconsideration level.Hetlioz was ordered to treat the enrollees non 24-hour sleep/wake cycle. The 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 the appeal and determined that the plan is not required to cover Hetlioz. 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: Favorable

At issue is Aimovig 140 milligrams/milliliter autoinjector prescribed for migraine prophylaxis. 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Aimovig 140 milligrams/milliliter autoinjector for migraine prophylaxis. Your plan has prior authorization requirements for this biologic that must be met before they will cover the requested biologic. The medical records submitted indicate that you have 4-14 migraines per month and that you have tried and failed Amitriptyline, Metoprolol Succinate, and Topiramate. In addition, the provider has attested that Aimovig will not be used in combination with Ajovy, Vyepti, and/or Emgality. The documentation provided does show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Aimovig 140 milligrams/milliliter autoinjector.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol sulfate 2.5 milligram/3 milliliter solution prescribed for chronic obstructive pulmonary disease/emphysema. The Part D plan denied your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the Albuterol sulfate is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Albuterol sulfate. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan prescribed for your condition. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The documentation submitted does not include the prescriber's information, enrollees diagnosis or the enrollee's contact information. Therefore, we were unable to ask the prescriber to send us medical records or other documentation to show why you need this medication.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 a tiering exception request for Creon DR 24000 unit capsules 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.Creon DR is a brand biologic on Tier 3 of the plans formulary. There are no brand biologics of the same type on the lower cost sharing tiers. Therefore, this biologic 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 Livalo 2 milligram tablets prescribed for hyperlipidemia. 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. Livalo 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

You requested Nubeqa 300 milligram tablet to treat metastatic castration resistant prostate cancer. 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 Nubeqa to treat your metastatic castration resistant prostate cancer. However, the Medicare approved compendia do not support the use of this drug for your condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. As such, an exceptions request based on medical necessity cannot be considered because the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Nubeqa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sildenafil Citrate 100 milligram tablets. 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 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 submitted medical records indicate that Sildenafil Citrate has been prescribed for benign prostatic hyperplasia with lower urinary tract symptoms. 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 Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Favorable

You requested Estradiol Patch .05 milligram/day prescribed 8 per 28 days to treat vasomotor symptoms of menopause and prevention of osteoporosis. 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. Your medical records show your doctor prescribed Estradiol Patch .05 milligram to treat vasomotor symptoms of menopause and prevention of osteoporosis. The documentation satisfies the plans coverage criteria. The required acknowledgement of the high risk nature of this medication was received. A physician reviewed your appeal and determined that the plan is required to cover Estradiol Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligrams prescribed 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 a request for coverage of Calcipotriene 0.005% ointment. The Part D plan denied the request for coverage because the prior authorization requirements were not met due to the enrollees diagnosis.  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 Calcipotriene ointment has been prescribed for the treatment of localized scleroderma morphea. However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, 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 Calcipotriene ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Stelara 90 milligram/milliliter syringe prescribed to treat Behcets 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 Stelara to treat your Behcets 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 Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for nerve pain secondary to costochondritis. 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 Lidocaine 5% patch to treat nerve pain secondary to costochondritis. 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 Lidocaine patch.