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

You requested Methylphenidate HCL 10 milligram tablets prescribed as directed for obstructive sleep apnea. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. 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 also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Methylphenidate HCL 10 milligram tablets to treat your obstructive sleep apnea. 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 Methylphenidate HCL because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Breztri Aerosphere 160-9-4.8 micrograms/actuation inhaler prescribed as directed for mild intermittent asthma. The Part D plan denied your request for a tiering exception because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. At coverage determination and redetermination, a diagnosis of mild intermittent asthma was provided. The plan requested additional information from the physician regarding the enrollees condition. The physician states the enrollee has failed treatment with other medication. However, the physician has not provided an additional diagnosis or medical records to support a different diagnosis for the requested drug. The Medicare approved compendia do not support the use of this drug for mild intermittent asthma.A physician reviewed your appeal and determined that the plan is not required to cover Breztri Aerosphere.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Theophylline ER 300 milligram tablets prescribed daily for unspecified asthma. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration request. We performed and 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. Theophylline ER is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan, 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.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Verzenio 150 milligram tablet prescribed for ER/PR positive HER2 negative left breast cancer. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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 records submitted at the reconsideration level. The medical records show you prescribed Verzenio as part of neoadjuvant treatment with Anastrozole for tumor reduction prior to surgery. Based on the neoMONARCH Phase 2 trial, Abemaciclib plus Anastrozole demonstrated biological and clinical activity with generally manageable toxicities in patients with HR positive HER2 negative early breast cancer. Abemaciclib led to potent cell-cycle arrest, and in combination with Anastrozole, enhanced immune activation. The Phase 2 trial is currently enrolling in Phase 3. Medicare approved journals support the use of Verzenio for the enrollees condition. Therefore, payment can be allowed.  An oncologist reviewed your appeal and determined that the plan is required to cover Verzenio.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Epclusa 400-100 milligram tablet prescribed as directed for chronic viral hepatitis C. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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 records submitted at the reconsideration level. Your medical records show you were prescribed Epclusa for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. We received additional medical record documentation. There is no evidence of cirrhosis on laboratory assessments provided. The genotype, in this case, does not affect the decision-making regarding treatment according to guidelines for simplified treatment per the American Association for the Study of Liver Diseases (AASLD) for this treatment naive enrollee. The records provided support coverage criteria has been met for simplified treatment.  A prior authorization exception is granted. Therefore, the drug can be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is required to cover the Epclusa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Repatha 140 milligrams per milliliter syringes. The Part D plan denied your request because the medication was not included on the plans formulary and 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. The documentation supports that Repatha has been prescribed to treat the enrollees hypercholesterolemia. However, the prescriber has not sufficiently addressed why all alternatives required by the plan to treat this condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Morphine Sulfate Extended Release 30 milligrams prescribed every eight hours for post-laminectomy syndrome and myositis ossificans. The Part D plan denied your request for a tiering exception because there are no lower tier alternatives of the same type for your condition. 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. Morphine Sulfate Extended Release is a generic 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. There is no generic drug on a lower eligible tier of the same type that is used to treat your condition. Therefore, your plan is not required to offer you a lower cost share.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lovenox 150 milligrams/milliliter Syringe subcutaneous prescribed for deep vein thrombosis. The plan denied the appeal because this drug is not listed on your formulary plan (non-formulary). 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. Your medical records show your doctor prescribed Lovenox for your deep vein thrombosis. This brand name drug is not listed in your plans formulary for your condition. Your doctor did not indicate that you tried Enoxaparin, which is listed on your plans formulary and why the drug would not work as well. Therefore, the requested drug cannot receive a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Lovenox because the documentation does not show that you have met the coverage criteria per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Corlanor 7.5 milligram tablets prescribed twice daily for inappropriate sinus tachycardia. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. 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 also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Corlanor 7.5 milligram tablets to treat your inappropriate sinus tachycardia. 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 Corlanor because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Febuxostat 40 milligram tablets daily to treat gout. 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 also researched Medicare systems and reviewed the enrollment data available. 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Febuxostat 40 milligram tablets. A physician reviewed your appeal and determined that the plan is not required to cover Febuxostat 40 milligram tablets because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xtampza ER 27 milligram capsules prescribed as directed for chronic low back pain. 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 documentation shows that the enrollee has tried and failed some of the alternative drugs on the plans formulary. The documentation also shows the enrollee has had previous reactions to topical medications. However, 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 Xtampza ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cosentyx Sensoready Pen to treat ankylosing spondylitis. The Part D plan denied your request for a non-formulary exception. We received an expedited 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 records submitted at the reconsideration level. The prescriber has not provided patient specific clinical rationale 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 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 Sildenafil 20 milligram tablets (180 per 30 days) prescribed for left ventricular failure, mild right heart failure, end stage heart failure, and pulmonary hypertension (not specified as World Organization Group I). The Part D plan denied your request because the off-label use of this drug for your condition is not medically accepted. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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. The Medicare approved compendia supports the use of the requested drug, as prescribed, for the treatment of the enrollees condition.  However, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria. Namely, the prior authorization requires the enrollees diagnosis be pulmonary arterial hypertension (World Health Organization Group I) and confirmed by a right heart catheterization. A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitriol 0.25 microgram oral capsule prescribed daily for end-stage renal disease. The Part D plan denied your request because drugs used to treat end-stage renal disease when the enrollee is on dialysis are covered under Medicare Part B. 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 also researched Medicare systems and reviewed the enrollment data available. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.Medicare records show you are not receiving dialysis. Therefore, the requested drug is not covered under Medicare part B. On reconsideration, the physician states you are a kidney transplant patient and prescribed Calcitriol to treat secondary hyperparathyroidism. However, no medical records were received from the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 mg to treat small intestinal bacterial overgrowth.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  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 provided medical records dated 2/4/2021 support that the requested drug is being used to reduce the risk of small intestinal bacterial overgrowth.  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 Leflunomide 20 milligram tablet prescribed for rheumatoid arthritis. The plan denied the appeal because your prescriber did not explain why you could not take any of the lower cost drugs that Humana offers for your condition. 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.The record shows your doctor prescribed Leflunomide for your rheumatoid arthritis. A Medicare approved compendium supports the use of the requested drug for your condition. However, the documentation submitted is insufficient to determine why you cannot take any of the lower costing drugs for your condition. Therefore, a cost-sharing tiering exception cannot be allowed at this time.A physician reviewed your appeal and determined that the plan is not required to cover Leflunomide because the documentation submitted is insufficient to determine why you cannot take any of the lower costing drugs for your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 75 milligrams capsules prescribed twice a day to treat low back pain and lumbar radiculitis. The Part D plan denied your request for a tiering exception for this covered drug at a lower cost tier. We received an expedited 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 documentation shows Pregabalin is a generic drug on Tier 3 of the plans formulary. There are no other drugs of the same type on the lower cost sharing tiers to treat the enrollees condition(s). 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 Livalo 2 milligram tablets daily to treat mixed hyperlipidemia. 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 also researched Medicare systems and reviewed the enrollment data available. 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Livalo 2 milligram tablets. A physician reviewed your appeal and determined that the plan is not required to cover Livalo 2 milligram tablets because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humulin R U-500 concentrated solution for subcutaneous infusion prescribed as directed for type II diabetes mellitus. 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 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 Humulin R U-500 is being administered via an infusion pump in the enrollees home. Therefore, this drug is eligible for coverage under Medicare Part B. Drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We determined that the plan is not required to cover Humulin R U-500 concentrated solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Xarelto, 20 milligram tablets. We received an auto-forwarded reconsideration request from your plan. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. Xarelto is a brand drug on Tier 3 of your 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. Therefore, a lower cost tiering exception cannot be granted for the Xarelto.A physician reviewed your appeal and determined that the plan is not required to cover the Xarelto at a lower cost tier.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Stivarga 40 mg three capsules to be given once a day for malignant neoplasm of the colon with metastasis to the lungs and skin..   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 that the enrollee have satisfied the following requirements:  The member has a diagnosis of metastatic colorectal cancer AND The member is using Stivarga (regorafenib) as monotherapy AND The member has documented intolerance, contraindication or has failed previous treatment with ALL of the following therapies: fluoropyrimidine (regimens include 5-FU/capecitabine),oxaliplatin-based chemotherapy,irinotecan-based chemotherapy, and anti-VEGF therapy (e.g., bevacizumab, ziv-aflibercept) AND If the member is RAS wild-type and has documented intolerance, contraindication or has failed previous treatment with anti-EGFR therapy (e.g., cetuximab, panitumumab).  The prescriber was asked to address these requirements.  The prescriber stated on 3/5/2021 that the enrollee tried and failed 6 cycles of Bevacizumab.  As well, the prescriber stated that anti-EGFR therapy was not recommended due to a positive pathology report for KRAS mutation.  The pathology report and supporting, relevant medical records were provided.  The documentation satisfies the plans coverage criteria.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.