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

At issue is a tiering exception request for Repatha SureClick 140 milligram/milliliter autoinjector pen to treat hyperlipidemia in an enrollee with atherosclerotic cardiovascular 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.Repatha Sureclick is a biologic drug on Tier 2 of the plans formulary. There are no biologic 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 Azathioprine50 milligrams prescribed daily for sarcoidosis. The Part D plan denied your request because it does not meet the criteria of 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Azathioprine50 milligrams daily to treat your sarcoidosis. 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 Azathioprine50 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Repatha 140 milligram/milliliter SureClick injection pen prescribed as directed for hyperlipidemia. 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 medical records show the doctor prescribed Repatha to treat hyperlipidemia. The Medicare approved compendia do support the use of Repatha for this condition.The enrollee does not satisfy the plan's coverage criteria.  However, the prescriber has indicated why all alternatives required by the plan would likely not be as effective as the requested drug for the enrollee, or would likely cause adverse reaction(s) to the enrollee. Office notes confirm intolerance to statins with gastrointestinal symptoms confirmed by gastroenterologist. Therefore, an exception to the plans coverage criteria is medically necessary.A physician reviewed your appeal and determined that the plan is required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tadalafil 20 milligrams prescribed daily for pulmonary hypertension. The Part D plan denied your request because it does not meet the criteria of 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Tadalafil 20 milligrams daily to treat pulmonary hypertension with obstructive sleep apnea and chronic obstructive pulmonary disease. 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 Tadalafil 20 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azelastine Hydrochloride/Fluticasone Propionate nasal spray prescribed for acute maxillary sinusitis and acute frontal sinusitis. The Part D plan denied a request for coverage for this off formulary drug because you did not have 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 Azelastine Hydrochloride/Fluticasone Propionate was prescribed to treat acute maxillary sinusitis and acute frontal sinusitis. However, the Medicare approved compendia does not support the use of this specific drug for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to cover Azelastine Hydrochloride/Fluticasone Propionate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for chronic pain. The Part D plan denied your request because the Plans prior authorization requirements were not met. 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 submitted documentation indicates Lidocaine was prescribed for chronic pain. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Favorable

You requested Gralise, 600 milligrams prescribed one tablet, three-times-daily for chronic pain syndrome and fibromyalgia. The Part D plan denied your request because diagnoses provided did not meet the requirements of a Food and Drug Administration 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. Your medical records show your doctor prescribed Gralise, to treat your chronic pain syndrome and fibromyalgia. Medicare approved compendium support the use of this drug for your conditions.  Micromedex/DrugDex supports Gabapentin (1,200-2,400 mg/day) is safe and efficacious for the treatment of pain and other symptoms associated with fibromyalgia. A physician reviewed your appeal and determined that the plan is required to cover Gralise because your diagnoses meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hizentra 10 grams prescribed weekly for common variable immunodeficiency. 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 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.Hizentra was ordered to be given in the home per subcutaneous pump. However, this drug is eligible for coverage under Medicare Part B. This medication given by external infusion pump for common variable immunodeficiency may be paid under Part B.We determined that the plan is not required to cover Hizentra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1% gel to treat low testosterone and male erectile dysfunction in an enrollee with Type 2 diabetes mellitus. 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.The enrollee does not satisfy the plan's coverage criteria. Safety and efficacy of Testosterone products in patients with age-related hypogonadism have not been established. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan would likely cause harm or not be as effective for the enrollee as the requested drug.  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 Gralise 600 milligrams prescribed three time daily for diabetic neuropathy. The Part D plan denied your request because the National Drug Code submitted for this drug indicates it is not an Food and Drug Administration approved 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 information submitted at the reconsideration level. The supporting statement submitted indicates that National Drug Code 13913-0005-19 is an Food and Drug Administration approved medication. We have confirmed that this National Drug Code is for a drug that is Food and Drug Administration approved. 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 the enrollees condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested amphetamine-dextroamphetamine 5 milligrams prescribed daily for fatigue related to multiple sclerosis. The Part D plan denied your request because it does not meet the criteria of 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed amphetamine-dextroamphetamine 5 milligrams daily to treat your fatigue related to multiple sclerosis. 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 amphetamine-dextroamphetamine 5 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Icatibant Acetate solution 30mg per 3 ml to treat Acquired Angioedema.   Prescriber indicates request is for 9 ml per day. The Part D Plan denied the request for both not a medically accepted indication and quantity limits exceeded.  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. Icatibant Acetate solution carries an Orphan Drug designation in the approved compendia for treatment of angioedema, without further qualification. It is being used for a medically accepted indication. The Plan limits the amount of Icatibant Acetate solution to 27 ml per 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 enrollees condition or would be likely to cause harm to the enrollee.  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

At issue is Avonex auto-injector pen kit prescribed for multiple sclerosis. The Part D plan denied your request because the documentation did not support an off-formulary exception since not all preferred drugs were previously tried. 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 physician submitted a supporting statement. The prescriber statement shows the physician had prescribed Avonex to treat multiple sclerosis. The Medicare approved compendium does support the use of this drug for multiple sclerosis. However, the records do not show why preferred alternatives on the plans formulary for the same condition have not been tried. Specifically, the documentation does not show that the enrollee has tried other formulary alternatives, or why the enrollee cannot take them.A physician reviewed your appeal and determined that the plan is not required to grant a non-formulary exception for the Avonex.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Jardiance, 25 milligram tablet prescribed once daily for diabetes mellitus. You asked the Part D plan to provide a cost-sharing tiering exception. The plan denied the appeal because there are no brand name drugs in the lower cost-sharing tiers that treat your condition. 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. Your medical records show Jardiance is being prescribed for your diabetes mellitus. A Medicare approved compendium supports the use of the requested drug for your condition. Jardiance is a brand name drug on Tier 3 of your plan. However, 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 cost-sharing tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Jardiance because there are no brand name drugs of the same type in the lower cost-sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligrams prescribed twice a day for the diagnosis of atrial fibrillation. The Part D plan denied your request for a tiering exception. We received a request to reconsider the appeal.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 record shows Eliquis was being prescribed for the prevention of deep vein clots in the setting of atrial fibrillation. Eliquis 5 milligrams is a brand name on Tier 3 of the plans formulary. There are no brand names of the same type on the lower cost-sharing levels. We have determined that the plan is not required to provide a tiering exception.Our decision does not address medical necessity of the drug. We made our decision only on the fact that it is not eligible for a tier exception under the Medicare Part D benefit. A physician reviewed your appeal and determined that the plan is not required to cover a tier exception for Eliquis 5 milligrams under your Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 250 milligrams prescribed daily for chronic fatigue and cancer-related fatigue.  A revised diagnosis of sleep apnea, unspecified was not supported as requested medical records were not received to support a diagnosis of obstructive sleep apnea confirmed by polysomnography. The Part D plan denied your request because it does not meet the criteria of 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. We also researched Medicare systems and reviewed the enrollment data available. Your doctor prescribed Armodafinil 250 milligrams daily to treat your chronic fatigue, cancer-related fatigue and sleep apnea unspecified. Medical records were not received to support the diagnoses. 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 Armodafinil 250 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gleostine 90 milligrams per meter squared prescribed to treat a primary brain tumor following appropriate radiotherapeutic procedures. The Part D plan denied your request because there are no conditions under which this request would be approved under Medicare Part D. 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.)You submitted a supporting statement and medical records. The medical records show you prescribed Gleostine to treat the enrollees malignant neoplasm of the brain. Medicare approved compendia support the use of the requested drug for the enrollees condition. The records also indicate that you have tried Temodar, Procarbazine Hydrochloride, Lomustine, Vincristine Sulfate, and involved-field radiation therapy. 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 Gleostine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cresemba 186 mg capsule to treat acute lymphoblastic leukemia, in remission, prophylaxis for invasive aspergillosis. The Part D plan denied the request stating that the provided diagnosis is not 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 Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 2 milligram tablets prescribed 1 per day for high cholesterol levels. 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. We also researched Medicare regulations and the plans enrollment data available. The prescriber indicated the enrollee had a statin intolerance. The medical records show the physician had prescribed Livalo to treat your high cholesterol. Medicares approved compendium supports the use of the requested drug for your condition.However, the records do not show why you cannot take other drugs on your plans formulary for your condition. The plans formulary has lower cost non-statin drugs that have not been tried. There must be indications that the enrollee tried the formulary alternatives before approving a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xyrem 500 milligram/milliliter oral solution prescribed as directed for narcolepsy with cataplexy. The Part D plan denied coverage because there was insufficient documentation to support that the prior authorization criteria were met. 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. We asked the prescriber to send us information regarding the enrollees condition. Specifically, we asked for medical records to corroborate the information on the prescriber statement. We did not receive the documentation requested.The prescriber statement shows the doctor prescribed Xyrem to narcolepsy with cataplexy. The Medicare approved compendia do support the use of Xyrem for this condition. The documentation available for review 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 Xyrem.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ambien CR 12.5 milligrams prescribed at bedtime for insomnia. 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. A physicians statement was submitted and stated you had tried Temazepam and over-the-counter diphenhydramine. Medicare approved compendia supports the use of the requested drug for your condition.However, the records do not show why you cannot take other drugs on your plans formulary for your condition. Specifically, these may include Belsomra, Dayvigo, Eszopiclone, Ramelteon, Trazodone, and Zaleplon.A physician reviewed your appeal and determined that the plan is not required to cover Ambien CR.