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

You requested is Spriva Respimat 2.5 microgram inhaler prescribed for chronic obstructive pulmonary 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 is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Repatha Sureclick 140 milligrams per milliliter pen to treat mixed hyperlipidemia. 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 enrollees low-density lipoprotein remained greater than 100 milligrams per deciliter despite treatment with both high intensity Atorvastin and Ezetimibe. The documentation satisfies the plans prior authorization criteria for Repatha. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Aimovig 140 milligram/milliliter autoinjector prescribed once monthly for migraines. The Part D plan denied your request because the quantity limits were exceeded. We received an auto-forwarded reconsideration request from the plan. 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 records show you prescribed Aimovig 140 milligram/milliliter autoinjector to treat the enrollees migraines. The prescriber statement indicates that one 140 milligram/milliliter auto injector is being requested per month. There is no indication the provider is requesting 140 milliliters, or 140 autoinjectors per month. The quantity limits have not been exceeded. Therefore, the plan is required to cover the requested quantity of one 140 milligram/milliliter autoinjector of Aimovig per 30 days.A physician reviewed your appeal and determined that the plan is required to cover the Aimovig 140 milligram/milliliter autoinjector, as the biologic did not exceed the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eliquis 5 milligram tablets prescribed twice daily. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The prescriber statement shows the enrollee has atrial fibrillation and was prescribed Eliquis for the prevention of stroke. No medical records were provided by the prescriber to support the enrollees 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 DA physician reviewed your appeal and determined that the plan is not required to cover Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Matulane 50 milligram capsules prescribed as directed for malignant neoplasm of the brain. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Matulane is a brand drug on Tier 5, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the specialty tier from the tiering exception process. 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 Adderall 30 milligram tablets prescribed for fatigue post breast cancer. The Part D plan denied your request because 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. The medical records show Adderall was prescribed to treat fatigue post breast cancer. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Adderall tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligrams tablets. The Part D plan denied a request for this drug. 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 information submitted at the reconsideration level. The physician submitted a supporting statement. The prescriber statement indicates that Otezla is prescribed to treat systemic lupus erythematous and chronic cutaneous lupus erythematosus. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s).A physician reviewed your appeal and determined that the plan is not required to Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue Synthyroid 88 micrograms tablets to treat the enrollees condition. The Part D plan denied the request.  The requested drug is not on the plans formulary. 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 provided a statement that did not include a diagnosis. In addition, a 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 was not received. 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 Xifaxan 550 milligrams prescribed for hepatic encephalopathy. The Part D plan denied your request for a tier change request because Xifaxan 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 plan shows Xifaxan is a brand name 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 Testosterone 50 milligrams per 5 grams gel pump 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.Testosterone 50 milligrams per 5 grams gel pump is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain 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.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 Flector 1.3% patches. The Part D plan denied a request for this drug because you did not have a medically accepted indication. 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 information submitted at the reconsideration level. The documentation indicates that Flector 1.3% patches were prescribed to treat osteoarthritis in shoulders and knees. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s). A physician reviewed your appeal and determined that the plan is not required to cover Flector 1.3% patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dofetilide. 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. There was no diagnosis or medical records to determine if the drug is medically indicated for the enrollees condition.  A physician reviewed your appeal and determined that the plan is not required to cover Dofetilide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 100 milligram capsules prescribed as directed for pain related to pancreatic cancer. The Part D plan denied coverage because the prior authorization criteria were not met. 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 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 Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Apokyn 10 milligrams to treat Parkinsons 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Rosuvastatin Calcium 5 milligram tablets. We received an auto-forwarded reconsideration request from the coverage level.We performed an independent and de novo review. To make our decision, we read your case file carefully. During the review we requested and received a prescriber statement and medical records from your doctor. We reviewed all documentation submitted. The records indicate that Rosuvastatin Calcium is being prescribed for the treatment of your hyperlipidemia. Rosuvastatin Calcium is a generic drug on Tier 2 of the plans formulary. The documentation submitted by your doctor does not address why the generic drugs of the same type on the lower tiers of the plans formulary to treat your hyperlipidemia have been tried and failed, or are contraindicated. Therefore, the plan is not required grant a lower cost tiering exception.A physician reviewed your appeal and determined that the Rosuvastatin Calcium is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Actemra 162 milligrams per 0.9-milliliter Solution prefilled syringe to treat polymyalgia rheumatica. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 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 reviewer determined that the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz 10 milligram tablets prescribed for Sezary syndrome. 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 Xeljanz for Sezary syndrome. In review of the Medicare approved compendia, Sezary syndrome is not a medically accepted indication for Xeljanz. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Xeljanz at issue. This decision does not address the medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit. The prior authorization requirements were not considered since this drug was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Pentasa 250 milligram capsule prescribed as directed to treat Crohns 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 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.Pentasa 250 milligram capsule is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Methenamine Hippurate 1gram prescribed for prophylaxis of urinary tract infection. The Part D plan denied your request for a tiering exception because Methenamine Hippurate is a brand name Tier 4 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 Methenamine Hippurate is a brand name Tier 4 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 Amphetamine-Dextroamphetamine 20 milligram IR tablets prescribed for fatigue related to multiple sclerosis and sleep apnea. The Part D plan denied your request because 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. The documentation shows the doctor prescribed Amphetamine-Dextroamphetamine for fatigue related to multiple sclerosis and sleep apnea. However, the Medicare approved compendia do not support the use of this drug for your condition.A physician reviewed your appeal and determined that the plan is not required to cover the Amphetamine-Dextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Daliresp 250 microgram tablets to treat the enrollees condition. The Part D plan denied the request. 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.Daliresp 250 microgram 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

At issue is Xifaxan 550 milligram oral tablet prescribed daily for irritable bowel syndrome with constipation. The Part D plan denied your request for a tiering 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. Xifaxan is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mekinist 2 milligram tablet to treat malignant melanoma of right upper limb. 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 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 Cabometyx 40 milligram tablets prescribed for hepatocellular carcinoma. The Part D plan denied your request because your condition is not a medically accepted indication for coverage of Cabometyx. 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 records show your doctor prescribed Cabometyx to treat hepatocellular carcinoma. The Medicare approved compendia supports the use of this drug for your condition in patients previously treated with sorafenib. The documentation provided indicates that you were not treated with sorafenib. Therefore, the medically accepted indication requirements have not been met. A physician reviewed your appeal and determined that the plan is not required to cover Cabometyx.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gabapentin 1,200 milligram capsule prescribed four times daily for polyneuropathy. The Part D plan denied your request because the quantity limit requested is higher than what the plan allows. 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 Gabapentin to treat your condition. The amount you were prescribed exceeds the plans number of doses that may be dispensed. There was no supporting evidence submitted to show why you require this amount. Therefore, an exception to the amount of drug requested cannot be made as the limit criteria was not met. A physician reviewed your appeal and determined that the plan is not required to cover the Gabapentin, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone. The Part D plan denied a request for this drug. 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 information submitted at the reconsideration level. The physician submitted a supporting statement. The prescriber statement indicates that Testosterone is prescribed for primary hypogonadism. The Medicare approved compendium does support the use of the requested drug.However, medical records have not been submitted for review. Therefore, the documentation available 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 Testosterone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diazepam 2 milligrams tablets. The Part D plan denied a request for this drug. 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 information submitted at the reconsideration level. The physician submitted a supporting statement. The prescriber statement indicates that Diazepam is prescribed to treat vertigo with Meniere disease.The use of the requested drug to treat vertigo with Meniere disease is an off-label use The Medicare approved compendium does support the use of the requested drug.However, the documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. A physician reviewed your appeal and determined that the plan is not required to cover Diazepam.