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

You requested Nicotrol Cartridge Inhaler prescribed for smoking cessation. The Part D plan denied the request for a formulary 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. The drug requested is not on the plans formulary. The medical records do not specifically address each formulary alternative and why they did not or would not work. A physician reviewed your appeal and determined that the plan is not required to cover a Nicotrol Cartridge Inhaler.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hizentra four grams/20 milliliter prescribed monthly for Cornelia De Lange syndrome. The Part D Plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received a reconsideration request.We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The record shows the drug is prescribed to be infused monthly over 1-2 hours for your condition. However, this drug is eligible for coverage under Medicare Part B. The Hizentra is being administered with an infusion pump that is covered by Medicare Part B durable medical equipment. Therefore, the drug may be covered by Medicare Part B.We determined that the plan is not required to cover the Hizentra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha SureClick Autoinjector140 milligrams per milliliter to treat mixed hyperlipidemia in an enrollee with clinical atherosclerotic cardiovascular disease.  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 has not provided 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. 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 Methylphenidate Hydrochloride 20-milligram tablets to treat attention deficit disorder, predominant inattentive type. 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 Nucynta 50 milligram tablets to treat fibromyalgia. The Part D plan denied your request because the documentation did not support an off-formulary 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. The prescriber has provided patient specific clinical rationale stating Hydromorphone is not suitable due to its addictive nature. 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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Nucynta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Topiramate 100 milligram tablets to treat anxiety and depression. The Part D plan denied the 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 these conditions. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azesco 13 milligram-1 milligram tablets prescribed for vitamin deficiency. The Part D plan did not provide a timely decision.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 drug requested is a prescription vitamin. Vitamins and minerals are excluded from coverage under Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Azesco.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Atropine Sulfate 1% Ophthalmic Solution prescribe for pseudoexfoliation open-angle glaucoma, severe stage, with eye pain. 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. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia does 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 Atropine Sulfate Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Myrbetriq ER 50 milligram tablets prescribed for overactive bladder. The Part D plan denied your 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. We also researched Medicare systems and reviewed the enrollment data available. Myrbetriq ER 50 milligram tablet 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. Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 1.5 milligram capsules prescribed for the enrollees condition. The Part D plan denied your request for a tier change request because Vraylar 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 Vraylar is a brand name Tier 5 drug, the specialty tier. 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

You requested Veltassa Packet 8.4 grams prescribed to treat hyperkalemia. 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 submitted documentation includes a questionnaire that indicates the enrollee had not experienced an inadequate treatment response, intolerance, or has a contraindication to Lokelma. The prior authorization requirements were not met. A physician reviewed your appeal and determined that the plan is not required to cover Veltassa Packet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Simponi to treat ileocolonic Crohns disease. 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 Viibryd 40 milligram tablet for bipolar disorder and major depressive disorder. 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.Viibryd 40 milligram tablet 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 Acthar Gel 80 units/milliliter prescribed for your rheumatoid arthritis. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation supports the drug was prescribed for your condition. However, you do not satisfy 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

You requested Restasis 0.05% Emulsion prescribed to treat keratoconjunctivitis sicca. The Part D plan denied your request for a formulary 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. The drug requested is not on the plans formulary. The records indicate the enrollee has tried and failed over the counter Refresh tears. The documents also show answers to questions that state all formulary agents would not be ineffective or have an adverse effect. There is no supporting evidence that all alternative formulary agents, for the enrollees condition, had been tried or are contraindicated.  A physician reviewed your appeal and determined that the plan is not required to cover Restasis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tagrisso 80-milligram tablet to treat non-small cell lung cancer without EGFR mutation. 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

You requested reimbursement for Prednisone 5 milligram tablets. 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 also researched Medicare regulations and Medicare approved compendia. You submitted receipts for the purchase of Prednisone on April 3, 2020, June 8, 2020, and September 18, 2020, for a total amount of $66.66. The submitted documentation did not include a diagnosis. There was no records to show why you were taking the drug or to determine if the drug is medically indicated for your condition. We asked the prescriber for additional information but did not receive a response.  A physician reviewed your appeal and determined that the plan is not required to reimburse the amount of Prednisone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brilinta 90 milligram tablets prescribed twice daily. 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.Brilinta is a brand drug on Tier 4 of the plans formulary. There are no brand drugs on 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 a tiering exception request for Dupixent 300 milligram/2 milliliter pen prescribed for atopic dermatitis. 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.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement of Imprimis Eye Drops prescribed for before and after cataract surgery. The Part D plan did not provide a timely decision. 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 also researched Medicare regulations and Medicare approved compendia. The drug requested is not on the plans formulary. The plan lists covered drugs in the formulary provided to enrollees. The drug was also not purchased at a preferred pharmacy. There was no indication of one of the exceptions, such as traveling or a medical emergency, that would be an exception to using a preferred pharmacy. A physician reviewed your appeal and determined that the plan is not required to reimburse the payment for Imprimis Eye Drops.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Humulin 70/30 100 units/milliliter suspension prescribed to treat the enrollees condition. The Part D plan indicated they approved the requested drug; however, the decision was not timely.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 plan has granted the formulary exception request for Humulin 70/30 100 units/milliliter suspension. The approval was not made timely. The requested drug has been approved coverage under Medicare Part D from January 16, 2021, through April 16, 2022.A physician reviewed your appeal and determined that the plan is required to cover Humulin 70/30 100 units/milliliter suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cinacalcet Hydrochloride 90-milligram tablet for treatment of end-stage-renal-disease on dialysis. The Part D plan denied the 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.Any drug or biological considered as renal dialysis services are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Part D coverage. 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 Prolia 60 milligrams/milliliter syringe prescribed as directed for osteoporosis. The Part D Plan denied your request for a tiering 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. Prolia is a biologic drug on Tier 4 of the plans formulary. There are no biologic 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 Mycophenolate Mofetil 250 milligram oral capsule prescribed for post-kidney transplant. The Part D Plan denied the request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We determined that the drug is eligible for Part B coverage. The beneficiary had a Medicare-covered transplant on October 4, 2018. Therefore, the drug can be considered for payment under the Part B benefit.A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate Mofetil. Immunosuppressant drugs are covered under Part B if they are used for transplant related purposes and if Medicare covered your transplant.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% adhesive patch to treat right shoulder pain.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Leflunomide 20 milligram tablets prescribed for seronegative rheumatoid arthritis. 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. We also researched Medicare regulations and Medicare approved compendia. Leflunomide is a generic drug on Tier 3 of the plans formulary. The plans formulary includes Methotrexate and Azathioprine on Tier 2 of the plans formulary. Your doctor did not address why these medications would not work for you. All generic drugs on lower tiers have not been tried. 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 Vascepa 1 milligram oral capsule prescribed twice daily for hypertriglyceridemia. 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 your doctor prescribed Vascepa to treat your hypertriglyceridemia. 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 Vascepa.