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

At issue is Tazarotene 0.1% cream prescribed daily for lamellar ichthyosis. 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 documentation supports the doctor prescribed Tazarotene to treat the Enrollees lamellar ichthyosis. 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 the appeal and determined that the plan is not required to cover Tazarotene. The prior authorization criteria states Tazarotene must be prescribed for a covered diagnosis. 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

At issue is Buprenorphine 2 milligram sublingual tablet prescribed for post laminectomy syndrome with chronic pain, the diagnosis given at initial determination and redetermination. 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. At reconsideration, the documentation shows Buprenorphine sublingual tablet was prescribed to treat the enrollees opioid dependence, in remission. The plan granted a 30 day supply for induction therapy. The records provided do not satisfy the plan's prior authorization criteria for maintenance therapy beyond 30 days.A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 1% gel prescribed for osteoarthritis of the right shoulder. 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 Diclofenac Sodium was prescribed to treat osteoarthritis of the right shoulder. However, the Medicare approved compendia do not support the use of this drug for the provided condition. A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium 1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyproheptadine Hydrochloride 2 milligram/5 milliliter syrup prescribed for anorexia The Part D plan denied the 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 determined that the plan is not required to cover Cyproheptadine Hydrochloride because it was used to treat anorexia. Drugs prescribed to treat anorexia, weight loss, or weight gain are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the Enrollee purchased drugs that are excluded, the Enrollee must pay for them. 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 Rybelsus 3 milligram tablet prescribed for type 2 diabetes mellitus with hyperglycemia. 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 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. 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 Rybelsus.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuzyra 150 milligram oral tablet prescribed for atypical mycobacterial infection of the lung. 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 Nuzyra to treat atypical mycobacterial infection of the lung with associated mycobacterium abscesses and nocardia criocigeorgia. 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 Nuzyra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Contour Next Test Strip. 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. Test strips, lancets, and needle disposal systems are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. However, this item may be eligible for coverage under Medicare Part B. We determined that the plan is not required to cover Contour Next Test Strip.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Betahistine Hydrochloride Powder 16 milligram capsules prescribed for vertifo. 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.We determined that the plan is not required to cover the drug at issue. Drugs compounded from bulk powders are not Food and Drug Administration approved and are therefore not covered under Part D. The plan does not offer supplemental (additional) coverage for this drug. If the Enrollee purchased drugs that are excluded, the Enrollee must pay for them. 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 a formulary exception request for Xeljanz XR 11 milligram tablets prescribed for rheumatoid arthritis. 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 documentation submitted did not include medical records or a supporting statement. A request for information was sent to the prescriber. The prescriber submitted medical records and 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 Xeljanz XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 0.5 milligram/2 milliliter nebulizer solution. 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 drug at issue is for use in a nebulizer in the Enrollees home. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this drug. If the Enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Uribel capsules. 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. Uribel capsules has an end marketing date on the Comprehensive National Drug Code Structured Product Labeling Data Elements File of January 31, 2020. There are no food and drug administration approved uses for this drug. Therefore, it is excluded from Part D drug benefit coverage. A physician reviewed your appeal and determined that the plan is not required to cover Uribel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus 1% Ointment to treat seborrheic dermatitis. 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 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 Praluent 75 milligram/milliliter pen 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 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 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 Azopt 1% Suspension to treat the Enrollees herpes simplex virus, keratouveitis. 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.Azopt 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 a tiering exception request for Testosterone 1% gel prescribed for male hypogonadism. 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. Testosterone 1% gel is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type to treat the enrollees condition on the lower cost sharing tiers. If there are no generic 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 request for coverage of Formula 3 Antifungal 1% solution. 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. Formula 3 Antifungal is available over the counter without a prescription. Nonprescription drugs are excluded from the Part D benefit. 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 a request for coverage of Otezla 30 milligram tablets prescribed for moderate to severe psoriasis. 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 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 Part D plan has prior authorization requirements that must be met before coverage of this medication will be approved. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Buprenorphine 5 microgram/hour patch prescribed for glioma. 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 attempted to obtain information from the prescriber regarding the enrollees condition and why the medication was needed. Specifically, we need records to show why other medications on the plan's formulary would not work.  However, we were unable to reach the prescriber. 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 documentation does not support why other drugs on the plans formulary would not work. A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cresemba 186 milligram capsules prescribed for fungal infection prophylaxis. 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 submitted documentation indicates the Cresemba at issue was prescribed for fungal infection prophylaxis. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300-milligrams/2-milliliters to treat atopic dermatitis. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 prescribed Prolia 6 milligram/milliliter prefilled syringe prescribed for age-related osteoporosis without current pathological fracture 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.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 Prolia to treat your age-related osteoporosis without current pathological fracture. 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 Prolia. 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

At issue is Trelegy Ellipta 100 microgram/umeclidinium 62.5 microgram/vilanterol 25-microgram inhalation prescribed twice 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. Trelegy Ellipta 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

At issue is Mesalamine 400 milligram delayed release capsule. 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 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 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 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 Dupixent 300 milligram per 2 milliliter pen-injector prescribed for prurigo nodularis. 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 Dupixent was prescribed to treat prurigo nodularis. 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 Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pradaxa 150 milligram capsule prescribed for an unknown diagnosis. The Part D plan denied your request because prior authorization requirements were not met. 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 did not receive the documentation requested.Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. 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 Pradaxa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Invokana 300 milligram tablet prescribed for type 2 diabetes mellitus. 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 medication is needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work.  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. A physician reviewed your appeal and determined that the plan is not required to cover Invokana.