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

At issue is Repatha Sureclick 140 milligram/milliliter auto-injector prescribed for primary hyperlipidemia. 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 prescriber indicates they prescribed Repatha SureClick 140 milligram/milliliter auto-injector to treat primary hyperlipidemia not associated with atherosclerotic cardiovascular disease, heterozygous familial hypercholesterolemia, or homozygous familial hypercholesterolemia. The prescriber also indicates that the enrollee is intolerant to statins which is also supported in the medical records submitted. The prescriber has also indicated that the drug will not be used in addition to Juxtapid or Praluent and the drug is being prescribed by, or in consultation with a cardiologist. The documentation provided supports you have satisfied the plan's prior authorization requirements. A physician reviewed your appeal and determined that the plan is required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Biktarvy 50-200-25 milligram tablets. 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. Biktarvy is included on Tier 5 of the plans formulary (list of covered drugs). Tier 5 of the formulary is the tier reserved for specialty drugs. The specialty tier is exempt from tiered cost-sharing expectations. Therefore, this drug is not eligible for coverage at a lower-cost tier. 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 Stelara 90 milligram/milliliter injection prescribed for hidradenitis suppurativa. 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 Stelara for hidradenitis suppurativa. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligram per 2 milliliters pen injector prescribed to treat asthma with eosinophilic phenotype. The Part D plan denied the appeal request.The QIC 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 that several of plans alternative formulary drugs were tried and failed or could cause harm. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the records do not support why all other drugs on the plans formulary would not work for the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Dupixent 300 milligram per 2 milliliters pen injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 50-milligram capsule to treat pain, unspecified. 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 Diclofenac Sodium 1 % gel prescribed for osteoarthritis of multiple joints, unspecified osteoarthritis type. 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 medical records show Diclofenac Sodium is prescribed for osteoarthritis of multiple joints. No specifics on the area of osteoarthritis was documented and the information had been requested. 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 Diclofenac Sodium 1 % gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gilenya 0.5-milligram capsule to treat multiple sclerosis, relapsing. 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.Your physicians office submitted a supporting statement. This medication is not on your plan's list of medications. The prescriber has not given a clear and valid medical reason why all medications required by the plan, on that list, did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. Therefore, an exception to the plans formulary coverage criteria is not supported.  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 Ondansetron Hydrochloride 8-milligram tablet to treat nausea and vomiting. 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 record shows you were prescribed Ondansetron to treat nausea and vomiting. We asked the prescriber to send us medical records verifying a medically accepted indication (diagnosis). However, we did not receive the documentation.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 Dronabinol 10 milligram capsule prescribed twice daily for anorexia, dementia, Down syndrome, and failure to thrive. 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 doctor prescribed Dronabinol to treat the enrollees anorexia, dementia, Down syndrome, and failure to thrive. However, the Medicare approved compendia do not support the use of this drug for these conditions.A physician reviewed the appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methadone 10 milligram tablet prescribed 90 tablets per 30 days for low back pain and cervical spondylosis without myelopathy. 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 your prescriber to send us information regarding the enrollee's condition. We also asked for medical records or other documentation to show why the enrollee needs this amount of the medication. We did not receive the documentation requested.. The documentation shows Methadone was prescribed to treat low back pain and cervical spondylosis without myelopathy. However, the documentation do not support why an exception to the plans quantity limit is medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover the Methadone 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 Trokendi Extended Release 50 milligram tablet prescribed for persistent migraine aura without cerebral infarction, not intractable, with status migrainosus. 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 requested additional information from the prescriber but did not receive the information requested. 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 the other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Trokendi Extended Release tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Aubagio 14 milligram tablets prescribed for multiple sclerosis. 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 requested additional documentation from the prescribing physician. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed. We included the received documentation in the review.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 submitted documentation does not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover the Aubagio at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diovan 160 milligram tablets prescribed to take one tablet, by mouth, daily to treat hypertension. The Part D plan denied the appeal request.The QIC 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 that a couple of plans alternative formulary drugs were tried and failed or could cause harm. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the records do not support why all other drugs on the plans formulary would not work for the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Diovan 160 milligram tablets prescribed.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 2.5 milligram tablets 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.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 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 Stivarga 40 milligram tablets prescribed for colon cancer. 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. Based on the information provided, the drug is not eligible for coverage under Part D. The sponsor of the clinical trial is not on the list of qualifying agencies. 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: Favorable

At issue is prescribed Revlimid 10 milligram capsule prescribed for diffuse large B-cell lymphoma, intra-abdominal lymph nodes. 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 records submitted at the reconsideration level. The documentation shows R-CHOP was tried as first line therapy and is considered first line therapy by the National Comprehensive Cancer Network. Therefore, the enrollee has satisfied the plan's coverage criteria. A physician reviewed the appeal and determined that Revlimid drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz 5-milligram tablet to treat rheumatoid arthritis. 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 formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not medically necessary. 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 Ukoniq 200 milligram tablet prescribed four tablets daily for chronic lymphocytic leukemia. 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 doctor prescribed Ukoniq to treat the enrollees chronic lymphocytic leukemia. However, the Medicare approved compendia do not support the use of this drug for this condition.A physician reviewed the appeal and determined that the plan is not required to cover Ukoniq.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zioptan 0.0015% ophthalmic solution prescribed to treat open-angle glaucoma. The Part D plan denied the appeal request.The QIC 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.Upon reconsideration, the submitted prescribers statement has been completed by the office Registered Nurse and shows that the plans alternative drugs, with the drug classification of prostaglandin, were tried and failed. However, Vyzulta is not confirmed as being tried and failed. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why all other drugs on the plans formulary would not work for the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Zioptan 0.0015% ophthalmic solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 3-milligram capsule to treat bipolar disorder, current episode depressed, severe, with psychotic features. 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 prescriber has not indicated that all alternatives required by the plan have been tried and failed, or why the plans required step therapy drugs would likely not be as effective as the requested drug.  Our physician reviewer's opinion is that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Droxidopa 100 milligram capsule prescribed for orthostatic hypotension. 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 enrollee does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plans coverage criteria for the requested drug.A physician reviewed your appeal and determined that the plan is not required to cover Droxidopa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Viberzi 75 milligram tablet prescribed for irritable bowel syndrome with diarrhea. 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 asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. However, we did not receive the documentation. 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, medical were not received to support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to Viberzi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Freestyle Libre 14 day sensor. The Part D plan denied the 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 item at issue is a medical device. 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 Avycaz 2.5(2/0.5)/gram Solution Intravenous. At initial determination and redetermination the diagnoses of pseudomonas aeruginosa infection and chronic sinusitis were. 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.At reconsideration, the diagnosis of multidrug-resistant pseudomonas isolate infection was given. The use of the requested drug to treat the provided diagnoses are off-label uses. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. 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

You requested Vitamin D3 50,000 unit capsules prescribed weekly for low vitamin D levels. 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, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to reimburse you for the Vitamin D3.