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

At issue is a tiering exception request for Buprenorphine 20 microgram/hour patch to treat the enrollees condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read 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.Buprenorphine is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  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 Myrbetriq ER 50 milligram tablets prescribed daily for urge incontinence, increased frequency of urination, and overactive bladder. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Myrbetriq ER 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. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Hydroxychloroquine 200 milligram tablet prescribed twice daily to treat lichen planpilaris. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read 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.Hydroxychloroquine 200 milligram tablet is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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

You requested Cyproheptadine HCL 4 milligram tablet prescribed daily for anorexia nervosa. The Part D plan denied your request. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We determined that the plan is not required to cover Cyproheptadine HCL because drugs used for anorexia 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

At issue is a tiering exception request for Stelara to treat the enrollees condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read 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 being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cinacalcet. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. The records submitted were insufficient to determine if the drug is being used for a medically accepted indication. We requested additional information from your prescriber but there was no response.   A physician reviewed your appeal and determined that the plan is not required to cover Cinacalcet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone-Ibuprofen 7.5-200 milligram table to treat low back pain and fibromyalgia. The Part D plan denied the request stating that 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.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records to show why the medication was needed. Specifically, we asked for records to show why other drugs on the plan's formulary would not work. We received the documentation and included it in our review.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 is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Keytruda 200 milligram tablets prescribed every three weeks for metastatic gastric adenocarcinoma. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.We asked the prescriber to send us a supporting statement and medical records to show the medical necessity for Keytruda. We received the documentation and included it in our review.The record shows the enrollee has metastatic gastric adenocarcinoma with PD-L1 mutation. The documentation shows the enrollee progressed on first-line FOLFOX and is now receiving Taxotere. The physician prescribed Keytruda as second line treatment for PD-L1 expressed tumor in combination with chemotherapy. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Keytruda.
Appeal type: Prescription Drug
Decision: Favorable

You requested Mekinist 2 milligram tablets prescribed as directed for multiple myeloma. 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 doctor prescribed Mekinist to treat multiple myeloma. The enrollee was previously treated with Velcade, Revlimid, and Dexamathesone, as well as Kyprolis and transplantation. Since 2017, the enrollee has been treated with Venetoclax and Velcade. The enrollee has persistent disease and KRAS mutation has been identified. The National Comprehensive Cancer Network guidelines show that the treatment options for relapsed disease are clinical trial or palliative care. An article from the Blood journal shows MEK inhibitors have been shown to block certain oncogene expressions in myeloma. According to an article in the Leukemia journal, Mekinist in relapsed/refractory myeloma patients caused 25-50% reduction in myeloma protein. The Medicare approved compendia do support the use of this drug for the enrollees condition. Mekinist is requested by the prescriber based on preclinical and clinical data for this enrollee who has refractory myeloma and KRAS mutation. The provider states if the enrollee does not have a chance to try this medication, the enrollee can have fatal progression of the disease. An exception to the plans coverage criteria is medically necessary for this enrollee. A physician reviewed your appeal and determined that the plan is required to cover Mekinist.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested foreign drugs prescribed while you were in the hospital outside of the United States. 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 your plans Evidence of Coverage, drugs purchased outside the United States and its territories are not covered. We determined that the plan is not required to cover the foreign drugs or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humalog 100 units/milliliter for subcutaneous injection prescribed as directed. 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 plan requested additional documentation from the prescriber to establish medical necessity. No medical records were provided by the prescriber to support the enrollees diagnosis and need for Humalog. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Humalog.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Travoprost 0.004% eye drops to treat the enrollees condition. 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 asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why the plans lower tiered drugs would not work for you. However, we did not receive the documentation.Travoprost 0.004% eye drops is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated that all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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 Omega 3-Acid 1-gram capsule to treat hyperlipidemia. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read 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 Dulera 200 micrograms-5 micrograms inhaler to treat chronic obstructive pulmonary disease. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request.  We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Dulera. A physician reviewed your appeal and determined that the plan is not required to cover Dulera because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablet prescribed as directed for irritable bowel syndrome with diarrhea. The Part D plan denied coverage because the plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level. Your medical records show you were prescribed Xifaxan for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has been met. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate 10 milligram tablet prescribed as directed for multiple sclerosis related fatigue. The Part D plan denied the request because it does not meet the criteria of a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. 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 you were prescribed Methylphenidate to treat your condition. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Methylphenidate because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Entresto 24/26 milligram tablet to treat the enrollees condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read 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 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 Budesonide EC three-milligram tablet prescribed for the enrollees refractory celiac disease. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia does 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is CellCept to treat panuveitis. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia does 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nitrofurantoin monohydrate macrocrystalline 100 milligram capsules, quantity 14, 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 plan submitted documentation that shows you were in the initial coverage stage of your Part D benefit and the drug was purchased at an out-of-network pharmacy. According to your plans Evidence of Coverage, Nitrofurantoin monohydrate macrocrystalline is a tier 3 drug with a copay of $47, in the initial coverage stage for an out-of-network pharmacy. The record shows the full price of the drug was less than the $47 copay amount. Therefore, your charge was based on the total cost of the drug. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram oral capsule prescribed daily for anorexia. The Part D plan denied your request because the requested drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The supporting statement and medical records show Dronabinol was prescribed to treat anorexia after a cerebral infarction. The medical records indicate the beneficiary has late effects of cerebrovascular accident. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colesevelam HCL 625 milligram tablet to treat bile salt induced diarrhea in an enrollee with Crohns disease.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xtampza ER 18 milligram capsules prescribed twice daily for pain. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The requested drug is being provided by your plan under a formulary exception. Xtampza ER 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 non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcitriol 0.25-milligram capsule. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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 also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Calcitriol 0.25-microgram capsule to treat secondary hyperparathyroidism. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug would be eligible for coverage under Part D. There is no information in the Medicare Database that indicates you are currently on dialysis. This drug in on the plans formulary and being used for a medically accepted indication.A physician reviewed the appeal and determined that the requested drug should be covered by the Part D plan.