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

At issue is Entresto 24 milligram-26 milligram tablet prescribed twice daily, a quantity of 60 tablets per 30 days for chronic systolic heart failure. 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. Your medical records show your doctor prescribed Entresto to treat your chronic heart failure. 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 Entresto. 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 request for coverage of Xeljanz 5 milligram tablets. The Part D plan denied the request because the prior authorization requirements were not met, as the medication was prescribed for a diagnosis not approved by the Food and Drug Administration. 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 Xeljanz has been prescribed for alopecia areata. 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 your appeal and determined that the plan is not required to cover Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Venclexta prescribed as directed for high-risk myelodysplastic syndrome. 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 enrollee has high-risk myelodysplastic syndrome. The enrollee was treated with Decitabine and was planning to receive an allogenic transplant, but the enrollee experienced disease progression. The treatment plan now includes a different hypomethylating agent, Azacitidine, in combination with the requested drug, Venclexta. The treatment plan was developed based on a likely impending transformation from high-risk myelodysplastic syndrome to acute myeloid leukemia. The provider submitted medical literature for review. However, the Medicare approved compendia do not support the use of this drug for the enrollees current condition. A physician reviewed your appeal and determined that the plan is not required to cover Venclexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rexulti 0.5 milligram tablets prescribed daily for attention-deficit/hyperactivity disorder, post-traumatic stress disorder, bipolar II disorder, and insomnia disorder. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read 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 shows the doctor prescribed Rexulti tablets to treat the enrollees attention-deficit/hyperactivity disorder, post-traumatic stress disorder, bipolar II disorder, and insomnia disorder. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed this appeal and determined that the plan is not required to cover Rexulti.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cinacalcet hydrochloride 30 milligram tablet prescribed daily, 90 days supply for the treatment of secondary hyperparathyroidism of renal origin. 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. According to Medicare rules, the requested drug cannot be approved for separate payment under Part D when it's for treatment on a patient who is receiving dialysis. Medicare records show the enrollee is actively receiving dialysis. Therefore, the Cinacalcet hydrochloride must be billed by the renal dialysis facility. We determined that the plan is not required to cover the Cinacalcet hydrochloride. Please submit your request for this drug through the dialysis provider.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue coverage for Colistimethate Sodium 150 milligram solution prescribed for a cystic fibrosis exacerbation with a Pseudomonas infection. 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not validated 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 prescribed Epclusa 400/100 milligram tablet prescribed for hepatitis C virus. 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 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. However, we did not receive medical records.The prescriber statement shows Epclusa was prescribed for hepatitis C virus. 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 Epclusa. 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 Testosterone Cypionate Solution 200 milligram/milliliter prescribed for androgen deficiency, hypogonadotropic hypogonadism, and hypopituitarism. 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. Your medical records show your doctor prescribed Testosterone Cypionate to treat your androgen deficiency. The notes do not support the diagnosis of primary hypogonadism.  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 Testosterone Cypionate. 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 Dronabinol 5 milligram capsules prescribed twice daily for anorexia. 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.We determined that the plan is not required to cover Dronabinol because it was prescribed to treat anorexia and promote weight gain. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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

You requested Prolia 60 milligram/milliliter syringe per 180 days prescribed for unknown diagnosis. 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 record shows the drug was supplied by the prescriber and administered to the enrollee in the prescribers office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined that the plan is not required to cover the Prolia. Please consider submitting your request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus 1 milligram capsule prescribed for relapsing immune checkpoint inhibitor-induced limbic encephalitis. 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 prescriber indicates you have relapsing immune checkpoint inhibitor-induced limbic encephalitis. You were prescribed Tacrolimus 1 milligram capsules. 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 Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trintellix 20 milligram tablets prescribed for the enrollees condition. 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.Trintellix 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 a request for coverage of Cyclobenzaprine Hydrochloride 10 milligram tablets. The Part D plan denied the request because the prior authorization requirements were not met, as the medication was prescribed for an indication not supported by Medicare references. 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 Cyclobenzaprine Hydrochloride has been prescribed for skeletal muscle spasms associated with chronic low back pain. 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 your appeal and determined that the plan is not required to cover the Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligram/milliliter syringe prescribed for the enrollees condition. 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. Repatha is a biological product on Tier 3 of the plans formulary. There are no biological products 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 Humulin R KwikPen 500 units per milliliter prescribed 300 units daily for 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.This drug is included on Tier 5 of the plans formulary. This Tier is identified as a Specialty Tier. The plan is not required to grant a tier exception for drugs available on their Specialty Tier. Therefore, a tier exception cannot be considered.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

You requested Nuedexta 20-10 milligram capsule prescribed for pseudobulbar affect. 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 medical records show your doctor prescribed Nuedexta to treat your pseudobulbar affect. The Food and Drug Administration-approved label for Nuedexta states the following: Nuedexta is indicated for the treatment of pseudobulbar affect. Pseudobulbar affect occurs secondary to a variety of otherwise unrelated neurologic conditions, and is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying. Pseudobulbar affect episodes typically occur out of proportion or incongruent to the underlying emotional state. Pseudobulbar affect is a specific condition, distinct from other types of emotional lability that may occur in patients with neurological disease or injury.In order to meet criteria for approval, the requested drug must be prescribed for treatment of pseudobulbar affect. The medical records submitted support the enrollee has a covered diagnosis. A physician reviewed your appeal and determined that the plan is required to cover Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alosetron Hydrochloride 0.5 milligram tablets prescribed for irritable bowel syndrome, diarrhea. 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 included on Tier 5 of the plans formulary. This Tier is identified as a Specialty Tier. The plan is not required to grant a tier exception for drugs available on their Specialty Tier. Therefore, a tier exception cannot be considered.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 Toujeo Max Solostar 300 units/milliliter injection prescribed for type 1 diabetes. 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. Toujeo Max Solostar is a biological products on Tier 3 of the plans formulary. There are no biological products 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 Myrbetriq ER 25 milligram tablets prescribed for other specified disorders of bladder/spastic bladder with benign prostatic hyperplasia with lower urinary tract symptom. 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. Myrbetriq ER is a brand name drug on Tier 4 of the plans formulary. There are no brand name 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 Shingrix 50 micrograms/0.5 milliliter intramuscular suspension reconstituted prescribed for the enrollees condition. 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. Shingrix is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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 Sodium sulfacetamide-sulfur 10-5% lotion prescribed for the treatment of rosacea.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 cover the Sodium sulfacetamide-sulfur lotion.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spiriva Respimat 2.5 microgram inhaler prescribed for the enrollees condition. 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. Spiriva Respimat is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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 Firmagon 120 milligram vial, 1 vial per 30 days prescribed for the treatment of prostate cancer. 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 record shows the drug was supplied by the prescriber and administered to the enrollee in the prescribers office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined that the plan is not required to cover the Firmagon. Please consider submitting your request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request and a tiering exception request for Repatha Sureclick 140 milligram/milliliter auto injector prescribed for hyperlipidemia. 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. Your physician submitted a supporting statement. The supporting statement did not indicate that the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick. Of note, as a formulary exception request cannot be made, a tiering exception request cannot be reviewed.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested EST Estrogens-Methyltest HS 0.625/1.25 milligram tablet prescribed daily for hormone replacement therapy. 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 documentation shows EST Estrogens-Methyltest HS 0.625/1.25 milligram tablet with a National Drug Code of a drug that has not been approved by the Food and Drug Administration. Drugs that have not been approved by the Food and Drug Administration do not meet the definition of a Part D Drug and are not eligible for coverage under the Part D Prescription Drug 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.