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

At issue is a request for a tiering exception for Eliquis 5 milligram tablets prescribed for superior mesenteric vein thrombosis. 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. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition 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 your appeal and determined that the plan is not required to cover the Eliquis at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Zenpep capsules of an unknown strength prescribed for an unknown condition. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. The documentation does not include any medical records from the prescribing physician. A request was submitted to the prescriber to provide a diagnosis and supporting medical records. A reply from the prescriber was not received. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 2.5%-Prilocaine 2.5% cream prescribed for pain control during needle cannulation. 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 record shows Lidocaine-Prilocaine was prescribed for dialysis-related services. Dialysis-related medications are included in the bundled payment that Medicare pays to dialysis centers under Medicare Part B. Therefore, this drug may be eligible for coverage under Medicare Part B. We determined that the plan is not required to cover Lidocaine-Prilocaine cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Victoza 3-pack 18 milligram/3 milliliter pen to treat type 2 diabetes mellitus. 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.Victoza 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 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 Rifaximin 200 milligrams tablets to treat small intestinal bacterial overgrowth syndrome.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 your doctor prescribed Rifaximin 200 milligrams tablets to treat small intestinal bacterial overgrowth syndrome. Rifaximin 200 milligrams tablets is not on the plans formulary. 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 Rifaximin 200 milligrams tablets.
Appeal type: Prescription Drug
Decision: Favorable

You requested Verzenio 150 milligram tablets prescribed as directed to treat 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.The record shows the enrollee has an 8.8 centimeter hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer. The enrollee was initially diagnosed with stage III breast cancer and underwent neoadjuvant therapy, followed by surgery. There was evidence of residual disease during surgery, but no evidence of metastatic disease was found. Imaging results also did not show distant metastatic disease. The physician prescribed Verzenio to be given in addition to adjuvant endocrine therapy. Abemaciclib combined with Endocrine Therapy for Adjuvant Treatment of HR-positive, HER2 negative, node positive, high-risk breast cancer, a phase III trial cited in the Journal of Clinical Oncology, supports the use of Verzenio for the treatment of this enrollee. The trial included patients with high-risk breast cancer that had greater than five centimeter disease and node positive disease. The patients were assigned to Abemaciclib (Verzenio) plus endocrine therapy, versus endocrine therapy alone. All patients had neoadjuvant therapy/radiation/adjuvant therapy. This trial showed that combination therapy improved invasive disease free survival. As such, a Medicare approved compendium supports the use of the requested drug for this enrollee; the drug has been prescribed for a medically accepted indication.The enrollee has not satisfied the plans prior authorization criteria that Verzenio be prescribed in combination with an aromatase inhibitor as initial endocrine therapy for the treatment of their disease. However, an exception to the plans prior authorization criteria is medically necessary for this enrollee and supported by medical literature. A physician reviewed your appeal and determined that the plan is required to cover Verzenio.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gemcitabine Hydrochloride 1 gram vial prescribed for metastatic bladder cancer and transitional cell carcinoma. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The records show you prescribed Gemcitabine Hydrochloride 1 gram vial to treat the enrollees metastatic bladder cancer and transitional cell carcinoma. However, this drug is eligible for coverage under Medicare Part B. This medication cannot be self-administered and will need to be provided incident to a healthcare professional service. We determined that the plan is not required to cover Gemcitabine Hydrochloride 1 gram vial. You may wish to submit your claim to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mekinist 2 milligram tablets prescribed daily for metastatic pancreatic 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. The documentation shows the doctor prescribed Mekinist to treat metastatic pancreatic cancer. The record shows the enrollee was initially diagnosed with pancreatic cancer in 2018. The enrollee was treated with neoadjuvant Folinic Acid, Fluorouracil, Irinotecan, and Oxaliplatin, followed by radiation and Gemcitabine, and then surgery. However, the enrollee was found to have lung involvement; the majority of areas were resected in December 2020. Molecular profiling showed that the cancer was KRAS positive. Because KRAS and MEK are all part of a signaling pathway for cancer pathogenesis, a MEK inhibitor was recommended by the prescriber. The provider submitted medical literature for review. 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 Mekinist.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nubeqa 300 milligram tablets prescribed for metastatic castration resistant prostate 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 records submitted at the reconsideration level. Your medical records show your doctor prescribed Nubeqa 300 milligram tablets to treat your metastatic castration resistant prostate cancer. The medical records submitted indicate that you are not a candidate for any further metastatic castration resistant prostate cancer treatment options. According to an open label phase 1 dose escalation and randomized phase 2 dose expansion trial published by Lancet Oncology, a Medicare approved journal, Nubeqa suppressed disease and had a favorable safety profile in patients with progressive metastatic castration resistant prostate cancer. Therefore, this is a medically accepted indication. In addition, your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided shows an exception to the prior authorization criteria can be made.An oncologist reviewed your appeal and determined that the plan is required to cover Nubeqa 300 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Methylphenidate Hydrochloride 20 milligram tablets. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Methylphenidate Hydrochloride has been prescribed for the treatment of multiple sclerosis related fatigue. 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 your appeal and determined that the plan is not required to cover Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for pain associated with relapsing multiple sclerosis. 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 your doctor prescribed Lidocaine 5% patch to treat your pain secondary to multiple sclerosis. 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 your appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cozaar 100 milligram oral tablet. 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. 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.There was no diagnosis given at initial determination. No medical records have been submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia. As such, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Cozaar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for a tiering exception for Bystolic 5 milligram tablets prescribed for hypertension. 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. Bystolic is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition 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 your appeal and determined that the plan is not required to cover the Bystolic at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligram/2 milliliter injection for allergic contact dermatitis due to food in contact with skin. 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 prescribers statement and medical records show Dupixent was ordered for treatment of allergic contact dermatitis due to food in contact with skin. However, 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 Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Valtessa 8.4 Gram powder packets prescribed for hyperkalemia. The Part D plan denied the request for coverage.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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria, with supporting medical records, and/or the coverage criteria are not satisfied by the provided medical records. 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 Spiriva Respimat Aerosol Solution 2.5 microgram/ACT prescribed for chronic obstructive pulmonary 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 Spiriva Respimat.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligram ER tablets prescribed as directed to treat overactive bladder. 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. Myrbetriq ER is a brand drug on Tier 4 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 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 Lansoprazole 3 milligram/milliliter compounding kit for gastroesophageal reflux. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Lansoprazole compounding kit made from bulk powder for gastroesophageal reflux.Drugs compounded from bulk powders are not Federal Drug Administration approved and therefore not covered under Part D. The plan is not required to cover the Lansoprazole compounding kit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate ER 12.5 milligram tablets prescribed to treat insomnia. 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 asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed.The prescriber indicates that several of plans alternative formulary drugs were tried and failed or could cause harm. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the records do not support why all 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 Zolpidem Tartrate ER 12.5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol sulfate 2.5 milligram/3 milliliter vial prescribed for Chronic respiratory failure. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows Albuterol sulfate is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Albuterol sulfate. 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

You requested Tylenol 325 milligram tablet prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan denied your request for reimbursement because valid National Drug Codes were not provided. The National Drug Codes provided were verified with the Food and Drug Administration. The numbers were invalid and therefore, not eligible for coverage or under Medicare Part D.  We determined the plan is not required to cover and provide reimbursement for the Tylenol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested compounded drug Ketotifen Fumarate 100% powder prescribed for unknown diagnosis.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 plan denied your request for reimbursement because the ingredients of the compounded drug do not meet the definition of a Part D drug. The National Drug Codes verified with the Food and Drug Administration, are not valid. Therefore, the compounded drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the compounded drug Ketotifen Fumarate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xanax 0.5 milligram tablet prescribed three times per day as needed for seizure disorder and insomnia. 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 Xanax for your seizure disorder. 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 Xanax.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nitrofurantoin Macrocrystals 100 milligram capsule daily for recurrent urinary tract infection. 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.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.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. A physician reviewed the appeal and determined that the plan is not required to cover Nitrofurantoin Macrocrystals.