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

At issue is Repatha 140 milligram per milliliter to treat hyperlipidemia. 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 prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gralise 300 milligram tablets prescribe to treat radiculopathy, cervicothoracic region. 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. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia do not support the use of the drug for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Gralise.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz XR 11 milligram tablet to treat rheumatoid arthritis. 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 documentation provided addressed the plans coverage criteria and all of the criteria were not satisfied. 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 Northera 300 milligram capsule three times daily to treat neurogenic orthostatic hypotension. 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 documentation provided addressed the plans coverage criteria and those criteria were not satisfied. 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 Ongentys 50 milligram prescribed for Parkinsons disease. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us additional information regarding whether alternatives to treat your condition on the plans formulary have been tried and failed. We did not receive the documentation requested. The records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Ongentys.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ambien 10 milligram tablets prescribed daily for insomnia. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Ambien.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Entresto 97 milligram-103 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.Entresto 97 milligram-103 milligram tablet 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Terbutaline Sulfate 5 milligram tablets prescribe for the diagnosis of chronotropic support in a heart transplant patient. 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. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia does not support the use of the drug for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Terbutaline Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Cevimeline Hydrochloride 30 milligram capsule to treat xerostomia due to past cancer treatment.   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 all documentation submitted. This includes 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, this drug is not eligible for a tiering exception.Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Myrbetriq Extended Release 25 milligram tablets prescribed to treat urge incontinence. The Part D plan denied the 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. This drug is being provided by the plan at the cost sharing level of Tier 3. There are no brand name drugs in the lower cost-sharing tiers to treat your condition. 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 Capecitabine 500 milligram tablet to treat breast cancer. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read all documentation submitted. This includes any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The record shows the enrollee received Capecitabine for breast cancer. However, this drug is eligible for coverage under Medicare Part B. Drugs covered under Part B are considered available (and excluded from Part D) if a beneficiary chooses not to pay premiums.We determined that the plan is not required to cover Capecitabine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Skelaxin 800 milligram tablets prescribe to treat muscle spasms related to 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 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. Medicare approved compendia indicates this drug is for acute, painful musculoskeletal conditions and is ineffective in the treatment of skeletal muscle hyperactivity secondary to chronic neurologic disorders. The approved compendia do not support the use of the drug for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Skelaxin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium Gel 1% prescribed for rheumatoid arthritis. The Part D plan denied your 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 initially provided the diagnoses of mesothelioma and intercostal pain.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  In the request for reconsideration, the prescriber clarified the diagnosis as rheumatoid arthritis.  Medical records were provided which support the diagnosis of rheumatoid arthritis.  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

You requested Oxcarbazepine 300 milligram tablets prescribed to treat partial seizures. The Part D plan denied the 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. This drug is being provided by the plan at the cost sharing level of Tier 3. Your doctor did not address why all alternative medications on the lower tiers would not work for you. 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 Gocovri ER 68.5 milligram capsule to treat Parkinsons disease. 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 prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Capecitabine 500 milligram tablets  prescribed for treatment of breast 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. Medicare rules state that drugs taken orally during cancer chemotherapy, provided they have the same active ingredients, and are used for the same indications as chemotherapy drugs that would be covered, if they were not self-administered, are covered under Part B. Part D excludes any drug for which payment would be available under Medicare Part B for that individual. The record shows the drug was prescribed to be used as an orally administered chemotherapy agent. We determined the Part D plan is not required to cover the Capecitabine. 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

At issue is Quetiapine Fumarate 25 milligram tablets, two tablets in morning and three tablets in evening, to treat psychogenic tremor disorder and conversion disorder. 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. The documentation does not satisfy the plans coverage criteria. 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 a prior authorization and quantity limit on Lidocaine 5% ointment prescribed three times a day (240 grams every 30 days) to treat bilateral knee osteoarthritis. The Part D plan approved the prior authorization for the maximum amount allowed but denied the request for an exception to the quantity limit. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We asked your prescriber to send us medical records including a diagnosis and documentation to support why the amount prescribed above the quantity limits was medically necessary. We received the documentation and included it in our review.. The medical records support the Lidocaine ointment is being used as a topical anesthetic for osteoarthritis in both of your knees. The plan limits the amount of Lidocaine 5% to 35.44 grams every 30 days. 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. 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

You requested Testosterone 30 milligram/1.5 milliliter pump prescribed for benign prostatic hypertrophy. 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 Testosterone for benign prostatic hypertrophy. The Medicare approved compendia do not support the use of this drug for your condition. 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

You requested Eliquis 5 milligram tablets prescribed to treat unspecified atrial fibrillation. The Part D plan denied the 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. This drug is listed at Tier 2 which is the lowest Tier allowed by your plan for this drug. You are being provided the drug at Tier 2 and the plan is not able to offer the drug at a lower cost share than what is being charged. 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 Vraylar 1.5 milligram capsules prescribed daily for bipolar I disorder, depressed. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. At reconsideration, a diagnosis of bipolar I disorder, depressed was given. The medical records submitted for review support this diagnosis. The Medicare approved compendia support the use of the requested drug for the enrollees condition.We asked the prescriber to send us a supporting statement and medical records showing prior therapy with Quetiapine, or an intolerance or contraindication to Quetiapine. However, we did not receive the documentation.The documentation available for review does not show that the enrollee has satisfied the plans coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Imatinib Mesylate 400 milligram tablets prescribed daily to treat chronic 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. We also researched Medicare regulations and Medicare approved compendia. The plan requires prior authorization requirements be met before covering this drug. The documentation provided, including electronic prior authorization, addressed the plans coverage criteria, which are approved by Medicare, and those prior authorization criteria were not satisfied.  A physician reviewed your appeal and determined that the plan is not required to cover Imatinib Mesylate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nubeqa 300 milligram tablets prescribe to treat metastatic castration sensitive prostate cancer. 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. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia do not support the use of the drug for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Nubeqa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ergocalciferol 50,000 unit capsules prescribed to treat vitamin D deficiency. 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. Vitamins and minerals are excluded from coverage under Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Ergocalciferol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Silodosin 4 milligram capsules prescribed to treat benign prostatic hyperplasia with lower urinary tract symptoms. The Part D plan denied the request for a formulary exception. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The drug requested is not on the plans formulary. There are no medical records that specifically address each formulary alternative and why they did not or would not work. A physician reviewed your appeal and determined that the plan is not required to cover Silodosin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Yonsa 125 milligram tablets prescribed for metastatic castrate-sensitive prostate cancer. 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 prescriber has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. A request for a supporting statement was sent to your physician; however, no further documentation was received. A physician reviewed your appeal and determined that the plan is not required to cover Yonsa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tymlos 0.80 microgram subcutaneous injection prescribed for post-menopausal osteoporosis. The Part D plan denied coverage.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 records submitted at the reconsideration level. The documentation on hand includes a physician supporting statement. The enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Famotidine 40 milligram tablets 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.Famotidine 40 milligram tablet is a generic drug on Tier 2 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.