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

At issue is a tiering exception request for Eliquis 5-milligram tablet to treat paroxysmal atrial fibrillation. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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.Eliquis is a brand drug on Tier 3 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.A physician reviewed the request and determined that the drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lumakras 120 milligram tablets prescribed as directed for KRAS G12C-mutated locally advanced or metastatic non-small cell lung 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. 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 Lumakras.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta Extended Release 50-milligram tablet to treat chronic back pain. The Part D plan denied the request. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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.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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 1 milligram pen-injector prescribed for diabetes. 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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The documentation shows Ozempic was prescribed to treat diabetes. 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 your appeal and determined that the plan is not required to cover Ozempic. 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 Lynparza 150 milligram tablets prescribed for the treatment of metastatic uterine leiomyosarcoma with RAD mutation. 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. The submitted documentation does not include any peer-reviewed, clinically relevant medical literature from an approved journal to support this appeal. Therefore, the requested drug is being prescribed for a non-medically accepted indication as defined by Medicare. As such, an exceptions request based on medical necessity cannot be considered because the requested drug does not meet the definition of a Medicare Part D drug. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Duexis 800-26.6 milligram tablet prescribed for osteoarthritis of bilateral knees. 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 documentation does not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Duexis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 2-milligram tablet to treat familial hypercholesterolemia. The Part D plan denied the request. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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.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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 3-milligram capsule Delayed Release to treat acute hepatitis. The case was auto-forwarded by the plan. 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 use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethegan 25 milligram suppository prescribed as directed for intractable vomiting with nausea epigastric pain and gas and gastroesophageal reflux 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. 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 Promethegan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Novolog flexpen units-100 insulin aspart 100 units per milliliter (3 milliliters) prescribed to administer 7 units subcutaneously with each meal to treat type II diabetes. The Part D plan denied the appeal 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 the ReliOn label of Novolog flexpen units-100 insulin aspart 100 units per milliliters. The requested drug, as prescribed, is not included in the plans formulary (list of covered drugs). The enrollees plan does not cover the requested ReliOn label, but does cover the Novo Nordisk label of the requested drug. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan 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.A physician reviewed the appeal and determined that the plan is not required to cover the ReliOn label of Novolog flexpen units-100 insulin aspart 100 units per milliliters.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement of $5.00 for Guanfacine Hydrochloride 1 milligram tablets purchased on May 3, 2021. The Part D plan denied the request for reimbursement because the drug was prescribed for a non-medically accepted indication. Additionally, the drug was not on the plans formulary and the documentation did not support a formulary exception.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 prescriber has noted that Guanfacine Hydrochloride has been prescribed for the treatment of Attention Deficit Hyperactivity Disorder, Autism Spectrum Disorder, and fluency disorder in conditions classified elsewhere.  However, the Medicare approved compendia do not contain any citations to support the use of the requested drug for the noted conditions. While the Medicare approved compendium, DrugDex, has a citation for the use of Guanfacine Hydrochloride for the treatment of Attention Deficit Hyperactivity Disorder in the pediatric population, there is no indication for its use to treat Attention Deficit Hyperactivity Disorder in adults. Therefore, the drug has been prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage, a formulary exception is not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to reimburse the amount paid for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Gemtesa 75-milligram tablets prescribed for overactive bladder. 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 requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed. However, we did not receive the requested information.The submitted documentation did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Gemtesa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Linzess 290 microgram capsules. 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. Linzess 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. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level. The drug will continue to be covered at the Tier 3 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcipotriene 0.005% cream prescribed at bedtime for two weeks then four weeks off for actinic keratoses. 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 Calcipotriene 0.005% cream to treat the enrollees actinic keratoses. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Calcipotriene 0.005% cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Januvia 100 milligram tablets. 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. Januvia 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. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level. The drug will continue to be covered at the Tier 3 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500 milligram tablet prescribed for central nervous system vasculitis. 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 Mycophenolate Mofetil was prescribed to treat central nervous system vasculitis. 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 2 milligram tablet prescribed for hyperlipidemia, unspecified. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documents submitted indicate that Livalo 2 milligram tablet is prescribed for hyperlipidemia. The documentation also states that the enrollee is unable to take statins. However, this drug 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 prescriber does not indicate why the other alternative on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ocrevus 300 milligrams per 10 milliliter solution prescribed for relapsing multiple sclerosis. 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. 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 all other drugs on the plans formulary would not work. A physician reviewed the appeal and determined that the plan is not required to cover Ocrevus 300 milligrams per 10 milliliter solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Quetiapine Fumarate 25 milligram immediate release tablet prescribed for major depressive disorder. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber indicates Quetiapine Fumarate 25 immediate release tablet is prescribed to treat major depressive disorder. However, Medicare approved compendia do not support the use of 25 milligram immediate release tablets of this drug for this condition.   A physician reviewed your appeal and determined that the plan is not required to cover Quetiapine Fumarate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine HCL 25 milligram solution prescribed for 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 documentation shows Promethazine HCL 25 milligram solution was prescribed to treat nausea and vomiting. 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 Promethazine HCL.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Fentanyl 75 micrograms per hour patch prescribed every 72 hours for chronic pain due to lumbar disc degeneration. 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 doctor prescribed Fentanyl patch to treat the enrollees chronic pain due to lumbar disc degeneration. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Fentanyl transdermal patch is indicated for pain management in opioid-tolerant patients, for pain severe enough to require daily, around-the-clock, long-term opioid treatment in which alternative treatments are not adequate.The records include a statement from the prescribing physician that the enrollee is stable on current medication regimen, continues to need the drug billed, and the benefit outweighs the potential risk.A physician reviewed the appeal and determined that the plan is required to cover Fentanyl 75 micrograms per hour patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kineret 100 milligram per 0.67 milliliter syringe prescribed for crystal-proven calcium pyrophosphate arthritis. 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 Kineret to treat the enrollees crystal-proven calcium pyrophosphate arthritis. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Kineret 100 milligram per 0.67 milliliter syringe.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Oxycodone 15 milligram tablets purchased 2-16-21 for 120 tablets, 3-15-21 for 120 tablets, and 4-12-2021 for 120 tablets. 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 requested additional information from the prescriber to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, the dose is appropriate, and the total amount of morphine milligram equivalent. We did not receive information that could answer these medical necessity issues.  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 reimburse payment for Oxycodone tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked for reimbursement for a nasal spray consisting of Dexamethasone 120 milligram/30 milliliter vial and Tobramycin 40 milligram/milliliter vial compounded drug prescribed for chronic sinusitis and hearing loss. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The prescriber indicates the compound drug is prescribed for chronic sinusitis and hearing loss. However, Medicare approved compendia do not support the use of these drugs for these conditions.  A physician reviewed your appeal and determined that the plan is not required to reimburse payment for Dexamethasone/Tobramycin Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuzyra 150 milligram tablet prescribed for left arm skin infection with culture showing Mycobacterium chelonae complex. 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 Nuzyra was prescribed to treat left arm skin infection with culture showing Mycobacterium chelonae complex. 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 Nuzyra.