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

At issue is Repatha Sureclick 140 milligram/milliliter prescribed for pure hypercholesterolemia. 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 Repatha was prescribed for pure hypercholesterolemia.. 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 Repatha. 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 a tiering exception request for Buprenorphine 5 microgram per hour weekly transdermal patches prescribed for chronic pain due to lumbar intervertebral disc degeneration. The Part D plan denied the tiering exception 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 Buprenorphine patches have been approved by the plan under a formulary exception. The drug 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 Flonase allergy relief 50 microgram spray for unknown diagnosis.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.According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to reimburse the enrollee for the Flonase allergy relief spray.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Acetaminophen 500 milligram tablet. 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. Acetaminophen 500 milligram tablet is available over-the-counter. Non-prescription drugs are excluded from Medicare Part D drug benefits.We determined that the plan is not required to reimburse you for Acetaminophen tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Ketoralac 10 milligram tablet. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, medical records supporting that medically accepted indication are required. These records were requested from the prescriber, and we did not receive information that could answer these medical necessity issues.  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 reimburse you for Ketoralac tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Melatonin 3 milligram tablet. 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. Melatonin 3 milligram tablet is available over-the-counter. Non-prescription drugs are excluded from Medicare Part D drug benefits.We determined that the plan is not required to reimburse you for Melatonin tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Procrit 10,000 units per milliliter prescribed every 14 days for anemia in chronic kidney disease, not on dialysis. 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.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 state the other drug on the plans formulary was not tried. A physician reviewed the appeal and determined that the plan is not required to cover Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Butalbital-APAP-Caffeine 50-325-40 milligram capsule prescribed as needed for tension headaches. 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.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 record states the other drug on the plans formulary (Butalbital-Acetominophen-Caffeine 50-325-40 milligram tablets) was not tried. A physician reviewed the appeal and determined that the plan is not required to cover Butalbital-APAP-Caffeine capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Bethanechol Chloride 25 milligram tablets. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Bethanechol Chloride has been prescribed for the treatment of gastroesophageal reflux disease. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix 50 microgram/0.5 milliliter intramuscular suspension kit. 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. Shingrix 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

At issue is Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed for arthropathy. 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 prescriber ordered Cyclobenzaprine Hydrochloride for arthropathy. A letter from the prescriber adds an additional diagnosis of chronic muscle spasms. The Medicare approved compendia do not support the use of the drug at issue for the enrollees conditions. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga. We received a reconsideration 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 systems and reviewed the enrollment data available.Farxiga 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 Jardiance. We received a reconsideration 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 systems and reviewed the enrollment data available.Jardiance 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 Corlanor 5 milligram tablet prescribed for supraventricular tachycardia paroxysmal tachycardia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician indicates Corlanor 5 milligram tablet is requested to treat supraventricular tachycardia paroxysmal tachycardia. However, 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 Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Amphetamine-Dextroamphetamine 20 milligram tablets. 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 documentation indicates that Amphetamine-Dextroamphetamine has been prescribed for major depressive disorder, post-traumatic stress disorder, and agoraphobia with panic disorder. However, the Medicare approved compendia do not contain any citations to support the use of Amphetamine-Dextroamphetamine for the treatment of the noted conditions. Although the drug is being used for non-medically accepted indications, the plan has approved coverage of the Amphetamine-Dextroamphetamine, which is on Tier 3 of the plans formulary. However, a tiering exception will not be granted by the plan for a drug that is being used for a non-medically accepted indication. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets prescribed for small intestinal bacterial overgrowth. 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 prescriber ordered Xifaxan for small intestinal bacterial overgrowth. 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 the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a co-pay reduction and reimbursement for Creon Delayed Release 12000 unit 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. Creon Delayed Release 12000 unit capsule 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. The drug is covered at the cost-sharing Tier 3 and 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 with reimbursement of a co-pay reduction.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Januvia 100 milligram tablets prescribed for type 2 diabetes mellitus. 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. Januvia is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the enrollees 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 Lidocaine 5% ointment prescribed for other postherpetic nervous system involvement. 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 prescriber ordered Lidocaine 5% ointment for other postherpetic nervous system involvement. 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 the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Glucagon Emergency Kit 1 milligram prescribed for an enrollee with diabetes. 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 prescriber indicates they prescribed Glucagon Emergency Kit due to type 1 diabetes mellitus, hypoglycemia, and insulin pump user. 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.  Please note that Gvoke HypoPen is available on the plan's formulary.A physician reviewed your appeal and determined that the plan is not required to cover Glucagon Emergency Kit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Armodafinil 250 milligram tablets. The Part D plan denied the request for coverage because the medication was being used for a non-medically accepted indication. 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 diagnosis initially provided by the prescriber to the Part D plan was fatigue associated with multiple sclerosis. The prescriber stated, 'Patient takes Armodafinil for fatigue related to MS.  Patient has been on medication since 2019.'  The Medicare approved compendia do not contain any citations to support the use of Armodafinil for the treatment of fatigue related to multiple sclerosis.At reconsideration, the prescriber has changed the diagnosis and noted that the enrollee has obstructive sleep apnea. However, no medical records or sleep study results have been submitted to validate the presence of obstructive sleep apnea. Therefore, there is insufficient documentation to determine if the requested drug is being prescribed for a medically accepted indication. As such, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligram/milliliter solution prescribed for the enrollees condition. The Part D plan denied the 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.Prolia is a biologic on Tier 4 of the plans formulary. There are no biologic drugs of the same type on the lower cost sharing tiers. Therefore, this biologic drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stiolto Respimat 2.5-2.5 microgram inhalant spray prescribed for the enrollees condition. The Part D plan denied the 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.Stiolto Respimat 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Mephyton 5 milligram tablet prescribed for the treatment of Crohn's disease and multiple vitamin deficiencies. The Part D plan denied the enrollees 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. According to Medicare rules, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Mephyton. The plan indicates that Mephyton is covered under the enrollee's supplemental benefits. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Entresto 24-26 milligram tablets prescribed for coronary disease with a compromised left ventricular ejection fraction of 25%. 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. Entresto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the enrollees 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 request for coverage of Lotemax 5% ophthalmic gel. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Lotemax has been prescribed for the treatment of other hereditary corneal dystrophies. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 15 milligram tablets prescribed for your condition. 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. Xarelto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the enrollees 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.