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

You requested Lynparza 150 milligram tablets prescribed as directed for metastatic cholangiocarcinoma. 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 Lynparza to treat metastatic cholangiocarcinoma. The records show the enrollee has been treated with Gemcitabine/Cisplatin, Folinic Acid/Fluorouracil/Oxaliplatin, and most recently, Capecitabine. The enrollee experienced disease progression through all regimens. The physicians treatment plan was to go to clinical trial, but molecular profiling showed ARID1A mutation. Therefore, the prescriber has requested treatment with Lynparza. 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 Lynparza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Incruse Ellipta 62.5 microgram inhalation powder 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 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. Incruse Ellipta 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 the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Duopa 4.63-20 milligram per milliliter enteral suspension prescribed for the management of Parkinsons 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. Duopa has been 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. A physician reviewed the appeal and determined that the plan is not required to grant a lower-cost tiering exception for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gilenya 0.5-milligram capsules prescribed daily for secondary progressive 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 Gilenya to treat your secondary progressive multiple sclerosis. 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 cover Gilenya. The documentation does not support you have a relapsing form of multiple sclerosis, including clinically isolated syndrome, and relapsing remitting disease. 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: Favorable

At issue is a request for coverage of Nexium DR 40 milligram delayed release capsules.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. The documentation indicates that Nexium DR has been prescribed in the treatment of gastroesophageal reflux disease without esophagitis. The prescriber has noted on the submitted prescriber statement that the enrollee has tried and failed the generic form of Nexium, Esomeprazole. The documentation does not indicate if the enrollee has symptomatic gastroesophageal reflux disease with heartburn. During this review, the prescribers office was contacted and the prescribers nurse did verify that the enrollee has symptomatic gastroesophageal reflux disease with heartburn, which is a medically accepted indication for the use of Nexium DR as outlined in the Medicare approved compendia. Nexium DR 40 milligram is included on the plans formulary. The plan does not include any prior authorization, step therapy, or quantity limit requirements for the drug. Therefore, since the drug is included in the formulary and is being used for a medically accepted indication, coverage for the drug can be allowed. A physician reviewed the appeal and determined that the plan is required to cover the Nexium DR 40 milligram delayed release capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Colistimethate Sodium powder for reconstitution prescribed for chronic pulmonary infections due to the presence of underlying cystic fibrosis. 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 requested drug is a bulk powder that is to be reconstituted with 0.9% sodium chloride so that it can be administered by a nebulizer. Bulk powders do not satisfy the definition of a Part D drug and are not covered by 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 Xolair 150 milligrams/milliliter prefilled syringe for subcutaneous injection prescribed as directed for severe, persistent asthma. 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. The medical records show the doctor prescribed Xolair to treat severe, persistent asthma. The 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 cover Xolair. 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 Novolog 70/30 vial prescribed 24 units daily for type 2 diabetes without complications. The Part D plan denied your request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The documentation indicates your doctor prescribed Novolog to treat your type 2 diabetes without complications. The drug at issue has a quantity limit of 40 per 28 days. The enrollee received 20 per 56 days and then attempted to get another 20 per 1 day. The quantity to days ratio exceeded the amount allowed by the plan. 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

You requested Cyclobenzaprine Hydrochloride 10 milligram tablet prescribed daily for skeletal muscle spasms. 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 Cyclobenzaprine Hydrochloride to treat your skeletal muscle spasms. However, the Medicare approved compendia do not support the use of this drug for your condition. Cyclobenzaprine Hydrochloride is to be used as adjunct therapy and for less than 3 weeks.A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% topical patches prescribed as directed. 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 Lidocaine for an enrollee with a history of fibromyalgia and chronic migraines. Upon reconsideration, the prescriber submitted a letter of medical necessity stating the enrollee also has a diagnosis of lumbar radiculopathy. However, the Medicare approved compendia do not support the use of this drug for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tukysa 50 milligram tablets prescribed for the treatment of metastatic urothelial cancer with HER2 mutation. 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 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 the use of the requested drug for the 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

You requested a formulary exception for Loteprednol Etabonate 0.5 percent drops prescribed as directed for the enrollees condition. 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 file carefully. We reviewed all documentation submitted. This includes the information 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 did not receive the documentation requested.The documentation shows your doctor prescribed Loteprednol Etabonate. It cannot be determined if the drug was ordered for a medically accepted indication because no diagnosis was provided.A physician reviewed your appeal and determined that the plan is not required to cover Loteprednol Etabonate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of a Freestyle Libre Sensor continuous glucose monitor prescribed for type 2 diabetes mellitus. The Part D plan your 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.Continuous glucose monitors are classified by Medicare as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as continuous glucose monitors. Coverage under Part D is excluded for any drug or item for which payment would be available under Part B. We determined that the Medicare Part D plan is not required to cover the continuous glucose monitor. This decision does not address the medical necessity or appropriateness of the item. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit your request for coverage to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Anoro Ellipta 62.5-25 microgram inhalation powder 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. Anoro Ellipta has been 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. A physician reviewed the appeal and determined that the plan is not required to grant a lower-cost tiering exception for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Adcirca 20 milligram oral tablet prescribed daily for pulmonary arterial 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. 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 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 Adcirca.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Spiriva Respimat 1.25 microgram per actuation inhalation spray prescribed for asthma. 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. Spiriva Respimat 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 the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Leukine 250 micrograms/vial prescribed as directed for relapsed neuroblastoma. 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 did not receive the documentation requested.The documentation shows the doctor prescribed Leukine to treat relapsed neuroblastoma. The prescriber states the enrollee is receiving Leukine in combination with single agent Dinutuximab. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. Additionally, there was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal.A physician reviewed your appeal and determined that the plan is not required to cover Leukine.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Repatha SureClick 140 milligrams per milliliter prescribed every two weeks for hyperliplidemia with atherosclerotic cardiovascular 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 the 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. We also asked for medical records or other documentation to show why this medication was needed. We received the documentation and included it in our review.The medical records show the doctor prescribed Repatha SureClick to treat the enrollees hyperliplidemia with documented atherosclerotic cardiovascular disease (cardiac stents). The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollee has failed to achieve goal low-density lipoprotein cholesterol and has failed therapy with 3 statins. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Repatha SureClick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 12.5 extended-release oral tablet prescribed daily for 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.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 Zolpidem Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Wakix 17.8 milligram tablets prescribed daily for hypersomnia with cataplexy. 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 Wakix to treat hypersomnia with cataplexy. 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 Wakix.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brilinta 60 milligram oral tablet prescribed daily. 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. Brilinta 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

You requested a formulary exception for Anoro Ellipta 62.5 microgram/1 Actuation-25 microgram/1 Actuation. 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.The submitted documentation does not include a supporting statement or medical records to support a prescribed diagnosis. A request for information was sent to the prescriber; however, no further documentation was 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 Dexilant 60 milligram capsule prescribed daily. 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. Dexilant is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is prescribed Testosterone Cypionate 200 milligrams per 10 milliliter intramuscular injection prescribed for testicular hypofunction. 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 also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Testosterone Cypionate for your testicular hypofunction. The plan requires for coverage of Testosterone when the enrollee two morning total serum (blood) testosterone levels of less than 300 nanograms/deciliter (10.4 nanomoles/liter) taken on separate occasions. The documentation includes clinical notes, which satisfied the plan's coverage criteria. A physician reviewed the appeal and determined that the Testosterone Cypionate is eligible for Part D coverage.