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

At issue is Nexletol 180 milligram tablet prescribed for atherosclerotic heart disease without angina pectoris and mixed hyperlipidemia. 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 Nexletol wast prescribed to treat your atherosclerotic heart disease without angina pectoris and mixed hyperlipidemia. 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 Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus Solostar 100 units/milliliter solution prescribed as directed. 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. Lantus Solostar 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: Unfavorable

You requested Methotrexate subcutaneous injection 250 milligram/10 milliliter prescribed for ankylosing spondylitis. 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 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 received the documentation and included it in our review. The documentation shows your doctor prescribed Methotrexate to treat your ankylosing spondylitis. 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 Methotrexate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Yupelri 175 microgram/3 milliliter inhaler solution prescribed for chronic obstructive pulmonary disease. 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 the drug at issue will be used by the enrollee at home. Drugs used in a nebulizer in the home may be covered by Part B. This drug is not eligible for coverage under Part D drug benefits. We determined that the plan is not required to cover Yupelri.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligram oral tablet prescribed for plaque psoriasis.  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 use of the requested drug to treat the provided diagnosis is an off-label use.  Provided office note of January 19, 2021, indicates psoriasis PGA (Physician Global Assessment) score is 2.0  mild. 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, at this severity.  Therefore, the requested drug, as ordered, is not being used for a medically accepted indication. The requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Vascepa 1 gram 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 Vascepa has been prescribed for the management of hypertriglyceridemia with elevated triglyceride levels between 150 milligrams per deciliter and 500 milligrams per deciliter in an enrollee that does not have established coronary vascular disease or a diagnosis of type 2 diabetes mellitus. However, the Medicare approved compendia do not contain any citations to support the use of Vascepa for the treatment of hypertriglyceridemia with triglyceride levels between 150 and 500 milligrams per deciliter in the absence of established cardiovascular disease or type 2 diabetes mellitus. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil 20 milligram tablets prescribed for pulmonary hypertension. 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 medical records submitted do not support pulmonary arterial hypertension, World Health Organization Group 1. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plans prior authorization requirements were not met. A physician reviewed your appeal and determined that the plan is required to cover Sildenafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cresemba 186-milligram tablet for prevention of invasive pulmonary aspergillosis in a patient with chronic myelomonocyctic leukemia. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 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 Androderm 2 milligram/24-hour patch prescribed for male hypogonadism. 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 Androderm to treat your male hypogonadism. The Medicare approved compendia supports the use of this drug for your condition. However, your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. 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 Androderm. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nulojix 250 milligram vial prescribed daily for kidney transplant. 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 determined that the plan is not required to cover the Nulojix. Medicare records indicate the kidney transplant period was from November 8, 2013 through November 24, 2013, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Nulojix is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 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 records submitted at the reconsideration level.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 requested documentation.The Part D plan denied your request stating that the plans prior authorization criteria was not met. Upon reconsideration, the prescriber indicates Zolpidem Tartrate 5 milligram tablets is prescribed to treat insomnia. No medical records have been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.A physician reviewed your appeal and determined that the plan is not required to cover Zolpidem Tartrate 5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gralise 300 milligram tablets prescribed for radiculopathy and restless leg syndrome. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Your doctor originally prescribed Gralise for radiculopathy and restless leg syndrome. Your doctor submitted a statement to indicate you have peripheral neuropathy. No medical records were received to support a diagnosis. A request for information was sent to your physician. Medical records were not received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Envarsus XR 4 mg tablets prescribed as directed. 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. This drug is not included on your plans formulary. Per Medicare rules, non-formulary drugs are 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 Alprazolam Extended Release 0.5 milligram tablets prescribed for generalized anxiety disorder. 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. Your prescriber indicates they prescribed Alprazolam Extended Release 0.5 milligram tablets for generalized anxiety disorder. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Alprazolone Extended Release tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metanx to treat peripheral neuropathy. 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.Metanx is a medical food classified as a vitamin that is prescribed under medical supervision. Vitamins are excluded from coverage under Medicare Part D. Therefore, this drug is excluded from coverage.A physician reviewed the appeal and determined that the requested drug is excluded from Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Braftovi 75 milligram capsules prescribed as directed for metastatic papillary thyroid 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. 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 enrollee needs this medication. We received the documentation and included it in our review.The documentation shows the doctor prescribed Braftovi, in combination with Mektovi, to treat metastatic papillary thyroid cancer. The physician states that the enrollee was initially treated with surgery and radioactive iodine. However, the enrollee experienced disease recurrence and there was evidence of metastatic disease within one year after completing treatment with radioactive iodine. The enrollee also experienced disease progression while being treated with Lenvima. The enrollee is currently being treated with Mekinist and Tafinlar, but the enrollee is unable to tolerate the side effects of these drugs. The prescriber also states the enrollee is BRAF V600E mutation positive. Medical literature was submitted by the prescriber for review. 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. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  A physician reviewed your appeal and determined that the plan is not required to cover Braftovi.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mektovi 30 milligram capsules prescribed as directed for metastatic papillary thyroid 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. 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 enrollee needs this medication. We received the documentation and included it in our review.The documentation shows the doctor prescribed Mektovi, in combination with Braftovi, to treat metastatic papillary thyroid cancer. The physician states that the enrollee was initially treated with surgery and radioactive iodine. However, the enrollee experienced disease recurrence and there was evidence of metastatic disease within one year after completing treatment with radioactive iodine. The enrollee also experienced disease progression while being treated with Lenvima. The enrollee is currently being treated with Mekinist and Tafinlar, but the enrollee is unable to tolerate the side effects of these drugs. The prescriber also states the enrollee is BRAF V600E mutation positive. Medical literature was submitted by the prescriber for review. 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. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  A physician reviewed your appeal and determined that the plan is not required to cover Mektovi.
Appeal type: Prescription Drug
Decision: Favorable

You requested Everolimus 5 milligram tablets prescribed as directed for metastatic 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 medical records show the doctor prescribed Everolimus to treat metastatic breast cancer. The medical records show the enrollee was initially diagnosed in 2017 and treated with Letrozole. In 2019, the enrollee experienced disease progression and was treated with single agent Faslodex. The enrollee has again experienced disease progression so the prescriber is requesting treatment with Everolimus, in combination with Aromasin (Exemestane). The National Comprehensive Cancer Network guidelines, a Medicare approved compendium, support the use of this drug for the enrollees condition. Specifically, the National Comprehensive Cancer Network guidelines state that to give a combination of Everolimus/Exemestane, inclusion criteria of the BOLERO 2 trial must be met. The medical records support that this enrollee meets the inclusion criteria of BOLERO 2 trial, as the enrollees disease was refractory to a nonsteroidal aromotase inhibitor.The enrollees medical records do not support the use of Anastrazole or Letrozole within the past year, as required by the plans prior authorization criteria. However, the Medicare approved compendia do not specify a timeframe for previous Anastrazole or Letrozole therapy. Furthermore, the enrollee experienced disease progression despite prior use of Letrozole through 2019. Therefore, an exception to the plans prior authorization criteria is medically necessary and is also supported by the Medicare approved compendia.A physician reviewed your appeal and determined that the plan is required to cover Everolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Zaleplon 5 milligram capsules prescribed for insomnia. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Incruse 62.5 microgram inhalation capsules prescribed for chronic obstructive pulmonary disease. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Incruse.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Restasis Multidose 0.05% eye drops prescribed for the enrollees condition. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Restasis Multidose 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: Unfavorable

You requested Gabapentin 300 milligram capsules prescribed for joint pain. 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 Gabapentin 300 milligrams for joint pain. 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 Gabapentin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Austedo 9 milligrams prescribed 2 tablets twice daily for tardive dyskinesia. 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 Tetrabenazine would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Austedo.