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

At issue is Praluent 75 milligrams/milliliter prescribed for the enrollees hyperlipidemia. 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 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 documentation supports the drug was prescribed for the enrollees diagnosis of hyperlipidemia. However, the enrollee does 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

At issue is Nexium DR, 40 milligram capsules prescribed for gastroesophageal reflux disease and Barrett's esophagus with dysplasia. 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 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 requested and submitted at the reconsideration level. A physician reviewed your appeal and determined that the plan is not required to cover Nexium DR. The submitted documentation shows that the drug was prescribed to treat gastroesophageal reflux disease Barrett's esophagus with dysplasia. The Medicare approved compendia support the use of the requested drug for these conditions. However, the submitted documentation does not include the enrollees medical records to validate that the plan's prior authorization coverage criteria for the Nexium DR have been satisfied.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine HCL 10 milligram tablet prescribed to treat torsion dystonia. The Part D plan denied the 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. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber was asked to send in medical records to support the diagnosis listed. A response from the prescriber was not received. Therefore, based upon the current record, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested azathriopine prescribed for the prevention of allograft rejection after heart transplantation. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. Your prescriber indicated this medication is to prevent rejection following a heart transplant. 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 azathriopine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 4 milligram tablet prescribed daily for hyperlipidemia. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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. We also researched Medicare systems and reviewed the enrollment data available.Your physician submitted a prescribers statement and medical records. The records show that the physician prescribed Livalo to treat your hyperlipidemia. The plan formulary includes other drugs that could be used to treat your condition. However, the records do not show all alternative drugs on the plan formulary have been tried for your condition or why they could not be tried to treat your condition.  The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit. A physician reviewed your appeal and determined that the plan is not required to cover an off-formulary exception for Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise ER 600 milligram tablets to treat post-herpetic neuralgia. 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 medical record shows Gralise ER 600 milligram tablets is being prescribed, to take 6 tablets per day, to treat the enrollees condition. The requested drug is not on the plans formulary. In addition, the prescribed daily dosage does not satisfy the Medicare approved compendia. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Sildenafil 20-milligram tablets to treat pulmonary arterial hypertension. The Part D plan denied the request stating that the provided diagnoses at the level of redetermination are a non-medically accepted indication. The diagnoses submitted were pulmonary fibrosis and systemic sclerosis. 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 is to treat the provided diagnosis of pulmonary arterial hypertension (PAH), associated with a connective tissue disease.  This is a subset in the WHO group I classification for PAH, and, therefore, is a medically accepted use of sildenafil. Additional medical records, including confirmatory right heart catheterization results, were submitted at the reconsideration level. The Medicare approved compendia do support the use of the requested drug, as prescribed, for the treatment of this condition.  Prior authorization criteria are met. Therefore, the requested drug is eligible for coverage under Medicare Part D.The physician reviewers opinion is that the plan is required to cover the drug.
Appeal type: Prescription Drug
Decision: Favorable

You requested Clobazam 20 milligrams 180 tablets for 30 days prescribed for intractable epilepsy. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. 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. Your medical records show your doctor prescribed Clobazam to treat your intractable epilepsy. Medicare approved compendia do support the use of this drug for your condition. The Plan limits the amount of Clobazam to 60 tablets every 30 days. The prescriber has indicated that the number of doses of the requested drug allowed by the Plan has not been effective in treating the condition.  Therefore, an exception to the Plans quantity limit coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Fentanyl 75 microgram/hour patch with a quantity of 15 patches per 30 days prescribed for chronic pain. The documentation shows Fentanyl is a generic drug on the enrollees plan. However, coverage for additional quantity above plan limits was approved by the plan for dates of service December 22, 2020 through January 21, 2022. The enrollee is requesting reimbursement for the Fentanyl filled on February 25, 2021. We received a reconsideration request.We conducted an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows the enrollee purchased Fentanyl on February 25, 2021 at the full price from a preferred retail pharmacy. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, documentation was provided showing that this claim was covered by the plan at the time of purchase. We determined that the plan is required to reimburse the enrollee the amount of total cash price paid, minus any applicable tiered copayment/coinsurance amount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Emgality 120 milligram per milliliter solution auto-injector prescribed daily for chronic migraines. 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 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. We also researched Medicare systems and reviewed the enrollment data available.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.Your medical records show your doctor prescribed Emgality to treat your chronic migraines. The Medicare approved compendia do support the use of this drug for your condition. The plan's coverage criteria require that there must be documented four or more migraine headaches per month and  standard migraine prevention must have been tried and failed 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 Emgality.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Diclofenac Epolamine 1.3 percent topical patch prescribed for acute right shoulder pain, sprain. The Part D plan denied your request because the drug is not covered on your plan's formulary or their list of covered drugs. 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. We also researched Medicare systems and reviewed the enrollment data available. The record shows Diclofenac Epolamine is being prescribed for acute right shoulder pain, sprain. The Medicare approved compendia supports the use of the requested drug for your condition. However, the drug is not one that is covered on your plan's formulary or their list of covered drugs. You did not indicate that all covered Part D drugs on any tier of the plan's formulary would not be as effective for the enrollee as the requested non-formulary drug, and/or would have adverse effects.The plan is not required to cover the Diclofenac Epolamine patch at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Citalopram Hydrobromide 40 milligram tablets prescribed as 90 tablets for 30 days. The Part D plan denied the request. We received an expedited 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. We also researched Medicare regulations and Medicare approved compendia. The coverage cannot be allowed for 90 tablets in a 30 day period. The plan allows 30 per 30 days. There is no supporting evidence submitted as to why the amount allowed by the plan would not be sufficient. The documentation is insufficient to allow an amount over the quantity limit.   A physician reviewed your appeal and determined that the plan is not required to cover 90 tablets for 30 days of Citalopram Hydrobromide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Naltrexone Hydrochloride, 50 milligram tablets, 150 per 30 days, prescribed for osteoarthritis. The Part D plan denied your request because the amount of drug requested (150/30) was above what is usually allowed under the plan. Additionally, the enrollee did not have a covered condition. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Naltrexone Hydrochloride because osteoarthritis is not a medically accepted indication to use this drug.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 law. As such, the requested drug does not meet the definition of a Medicare Part D drug and is therefore not eligible for coverage under Medicare Part D. Additionally, since the drug is not eligible for coverage under Medicare Part D, the amount prescribed will not be taken into consideration.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5 microgram/25 microgram inhalation powder prescribed for chronic obstructive pulmonary disease. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sutent 37.5 milligram capsules prescribed as directed for cutaneous melanoma. The Part D plan denied your request because drug was not prescribed for 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 documentation shows the doctor prescribed Sutent for cutaneous melanoma. The physician states that Sutent is the recommended treatment based on the specific mutations identified in this enrollee. 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 Sutent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Verzenio 100 milligram tablet prescribed twice daily for the treatment of a postmenopausal enrollee with hormone receptor-positive, human epidermal growth factor receptor 2-negative advanced breast cancer. 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 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 you prescribed Verzenio 100 milligram tablet in combination with an aromatase inhibitor to treat the enrollees advanced breast cancer. The Medicare approved compendia do support the use of this drug for this condition. However, the plan requires prior authorization criteria 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 Verzenio 100 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Dexilant DR (Dexlansoprazole) 30-milligram capsules prescribed daily for gastroesophageal reflux disease. The Part D plan denied your request for a tiering exception because Dexilant DR is a brand name Tier 4 drug and the lower cost-sharing tiers only contain generic alternative 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 record shows Dexilant DR is being prescribed for gastroesophageal reflux disease. The Medicare approved compendium supports the use of the requested drug for your condition. The plan shows Dexilant DR is a brand name Tier 4 drug. 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 tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Colcrys 0.6 milligram tablets prescribed for rheumatoid arthritis. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication, and the documentation did not support an off-formulary exception for 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 information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Colcrys for rheumatoid arthritis. The Medicare approved compendia do not support the use of the drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed. As the drug was not prescribed for a medically accepted indication, off-formulary exception criteria were not addressed.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 Vyvanse 70 milligram capsules prescribed daily for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue was covered as a formulary exception and was not eligible for a tiering exception. 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.Vyvanse is a non-formulary brand drug. Non-formulary drugs are covered by the plan on Tier 5 and 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 Brilinta 90 milligrams prescribed two tablets twice daily (120 per month) for myocardial infarction. The Part D plan denied your request because the quantity limit requirement was not met. The plan did approve 60 tablets per month. 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. We asked your prescriber to confirm the dosage ordered as the new documentation submitted stated you were to take one table twice a day. Your medical records show your doctor prescribed Brilinta 180 milligrams twice a day to treat your cardiovascular disease. The prescriber statement indicates the drug is required to reduce the risk of cardiovascular death. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover the requested quantity of Brilinta 120 tablets per 30 days. The plan has already approved 60 tablets per month.A physician reviewed your appeal and determined that the plan is not required to cover the Brilinta, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess capsule prescribed for irritable bowel syndrome. The Part D plan denied your request for a tiering exception. We received a reconsideration request from the plan. 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 documentation shows Linzess 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 for the enrollees condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Linzess.