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

You requested coverage for Zelnorm 6 milligram tablets prescribed daily for gastroparesis. 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 Zelnorm for gastroparesis. In review of the Medicare approved compendia, gastroparesis is not a medically accepted indication for Zelnorm. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Zelnorm at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested is Spriva Respimat 2.5 micrograms inhaler prescribed for your chronic bronchitis and restrictive lung disease. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. 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.Spriva Respimat 2.5 micrograms inhaler is a brand name 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 Rubraca 250 milligram tablets prescribed for metastatic, recurrent ovarian cancer that had a complete response to platinum-based chemotherapy. 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 Rubraca 250 milligram tablets were prescribed in combination with Avastin for maintenance of the enrollees metastatic, recurrent ovarian cancer that had a complete response to platinum-based chemotherapy. However, the Medicare approved compendia do not support the use of this drug, as prescribed, for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Rubraca 250 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Rhopressa 0.02 percent solution prescribed for primary open angle glaucoma bilateral moderate stage. The Part D plan denied your request for a tiering exception because Rhopressa 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 Rhopressa 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 coverage for Victoza 0.6 milligram per 0.1 milliliter subcutaneous injection pen. 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 Victoza is being prescribed for prediabetes, obesity, and insulin resistance. However, the Medicare approved compendia do not contain any citations to support the use of Victoza for the treatment of the noted conditions. Therefore, the requested drug is being prescribed for non-medically accepted indications 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 the Victoza subcutaneous injection pen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ingrezza 80 milligram capsule prescribed for blepharospasm. 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 Ingrezza 80 milligram capsule to treat the enrollees blepharospasm. 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 Ingrezza 80 milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xyosted Solution auto-injector prescribed for hypogonadism. 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. 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 Anoro Ellipta 62.5-25 microgram inhaler to treat chronic obstructive pulmonary disease. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has provided patient specific clinical rationale. However, medical records were not submitted to support 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 Xenical 120 milligram capsules prescribed for other, hyperlipidemia. The Part D plan denied your request because this type of drug is excluded from Part D coverage. 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 determined that the plan is not required to cover Xenical because drugs used for 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

At issue is a tiering exception request for Nexlizet 180 milligram-10 milligram tablet 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.Nexlizet is not on the plans formulary. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Crestor 20 milligram tablets for hypercholesterolemia. 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.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 3 milligram capsules prescribed to treat diarrhea related to the diagnosis of celiac 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 use of the requested drug to treat the provided diagnoses 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 your conditions. 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 Budesonide 3 milligram capsules.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Praluent 75 milligrams to treat hypercholesterolemia and atherosclerotic heart disease. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan requires for coverage of Praluent that the enrollee is at risk of myocardial infarction. The documentation includes clinical notes which satisfy the plan's coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hyoscyamine Sulfate 0.125-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.The plan denied the request for coverage of the requested drug to treat the provided diagnosis because the plans Medicare Part D drug plan cannot cover drugs classified as being part of the Food and Drug Administration (FDA)'s Drug Efficacy Study Implementation (DESI) program. These drugs are considered to be Less than Effective (LTE) per FDA review.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine-Naloxone 8-2 milligram sublingual tablet to treat opioid dependence. The case was auto-forwarded by the plan.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 plan limits the amount of Buprenorphine-Naloxone 8-2 milligram sublingual tablet to a quantity limit of three tablets-per-day. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Repatha SureClick 140 milligram/milliliter solution auto injector pen prescribed for an enrollee with coronary artery disease and hyperlipidemia. 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 record shows the enrollee tried and was intolerant to Lipitor, Crestor, Livalo, Pravastatin and Zetia. However, the formulary contains additional drugs and the documentation does not show why the enrollee cannot take one listed on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 100 milligram tablet to treat fatigue associated with seizures and seizure medications. 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.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 Perforomist 20 microgram/2 milliliters inhalation solution prescribed for your chronic obstructive pulmonary disease. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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. Your doctor prescribed Perforomist to treat your condition. The Medicare approved compendia support the use of this drug for your condition. However, the drug is administered with a nebulizer. Based on the information provided, the drug is eligible for Part B coverage.  Therefore, the drug is not eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is not required to cover Perforomist.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vimpat 50 milligrams prescribed daily for seizures. The Part D plan denied your request for a tier change request because Vimpat is in the specialty tier of your list of covered 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 record shows Vimpat is being prescribed for seizures. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Vimpat is a generic Tier 5 drug. Your plan does not allow you to receive drugs in this tier at a lower cost share.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amphetamine-Dextroamphetamine 10 milligram tablet to treat hypersomnia related to grade 4 anaplastic astrocytoma. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The 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 Lotemax SM Gel 0.38%. 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 Lotemax SM Gel was prescribed to treat purulent endopthalmitis, hypotony of eye and inflammation at bleb site due to thinning conjunctiva. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s). In addition, the prescriber statement states that the enrollee is discontinued from medication. As such, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Lotemax SM Gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Repatha SureClick 140 milligram/milliliter solution auto injector pen prescribed for an enrollee with hyperlipidemia, unspecified. 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 record shows the enrollee tried and was intolerant to Ezetimibe, fish oil and is intolerant to statins. However, the formulary contains additional drugs and the documentation does not show why the enrollee cannot take one listed on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amiodarone 200 milligram tablets prescribed for unknown diagnosis. 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.The record shows you received Amiodarone as a self-administered drug while in the hospital. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that you paid was not provided. Therefore, we determined that the plan is not required to reimburse you without the required documentation. Please submit proof of payment to your plan for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amlodipine 5 milligram tablets prescribed for unknown diagnosis. 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.The record shows you received Amlodipine as a self-administered drug while in the hospital. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that you paid was not provided. Therefore, we determined that the plan is not required to reimburse you without the required documentation. Please submit proof of payment to your plan for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clopidogrel 75 milligram tablets prescribed for unknown diagnosis. 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 you received Clopidogrel as a self-administered drug while in the hospital. The National Drug Code submitted for payment to your plan for the Clopidogrel was 00904-6291-61. We found that National Drug Code 00904-6291-61 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover the Clopidogrel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eliquis 5 milligram tablets prescribed for unknown diagnosis. 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.The record shows you received Eliquis as a self-administered drug while in the hospital. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that you paid was not provided. Therefore, we determined that the plan is not required to reimburse you without the required documentation. Please submit proof of payment to your plan for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Folic acid 1 milligram tablet prescribed for unknown diagnosis. 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 you received Folic acid as a self-administered drug while in the hospital. According to Medicare rules, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover or reimburse you for the Folic acid. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.