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

At issue is a tiering exception request for Eliquis 5-milligram tablet to treat atrial fibrillation. 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 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.Eliquis 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.A physician reviewed the request and determined that the drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Fentanyl 100-microgram/hour patch prescribed for post-polio syndrome and fibromyalgia. 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 requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the daily maximum morphine equivalent dose on hand per day. We received additional information and included it in the review.The documentation indicates the prescriber ordered the requested drug for the enrollees noted condition. The submitted documentation indicates the enrollee would have a daily morphine equivalent dose of 360 milligrams per day on hand. The plan has a quantity limit restriction of 200 milligrams of morphine equivalent per day. The prescriber has indicated on the submitted documentation that the daily morphine equivalent dose on hand per day does not exceed 200 milligrams/day. However, the cumulative daily morphine equivalent on hand is greater than 200 morphine milligram equivalence. Therefore, the drug at issue cannot be allowed.The plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocortisone Acetate 25 milligram suppository to treat hemorrhoids.   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 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 denied the request for coverage of the requested drug to treat the provided diagnosis because your plan's Medicare Part D drug plan cannot cover drugs classified as being part of the Food and Drug Administrations Drug Efficacy Study Implementation program. These drugs are considered Less Than Effective per Food and Drug Administrations review.A physician reviewed your appeal and determined that the plan is not required to cover the Hydrocortisone Acetate 25 milligram suppository.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Colesevelam Hydrochloride 3.75 gram powder packet prescribed for mixed hyperlipidemia. 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 requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed. The prescriber submitted medical records and a statement, which we included in this review.The submitted documentation did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Colesevelam Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24-26 milligram tablets prescribed to treat the enrollees condition. The Part D plan denied the appeal 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.Entresto 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

You requested Dorzolamide Hydrochloride/Timolol Maleate 2 percent-0.5 percent droperette prescribed as directed for active Graves disease bulging eyes. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows your doctor prescribed Dorzolamide Hydrochloride/Timolol Maleate to treat your active Graves disease bulging eyes. 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 Dorzolamide Hydrochloride/Timolol Maleate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20-milligram tablets prescribed for erectile dysfunction. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Sildenafil because it was prescribed for erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 25 milligram capsules prescribed for abdominal wall pain in left lower quadrant. 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 the drug at issue for the enrollees noted condition. 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 request for coverage of Memantine Hydrochloride 10 milligram tablets. The Part D plan denied the request for because the medication was being prescribed 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 documentation provided to the plan at the initial coverage determination indicates the requested drug is being prescribed for an unspecified mild neurocognitive disorder. The documentation provided to the plan, upon appeal, at redetermination, indicates that the requested drug is being prescribed for an unspecified mild to moderate neurocognitive disorder. At reconsideration, the prescriber has indicated that the requested drug is being prescribed for an unspecified major neurocognitive disorder. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of an unspecified neurocognitive disorder, whether the disorder is mild, moderate, or major. As such, the requested 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 request for coverage of Livalo (Pitavastatin Calcium) 2 milligram tablets prescribed for the treatment of hypercholesterolemia. 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. Livalo (Pitavastatin Calcium) is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient patient specific clinical rationale as to why all the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. The prescriber has noted that the enrollee is unable tolerate statins due to muscle pain; however, the requested drug, Livalo (Pitavastatin Calcium), is a statin. Therefore, this is not sufficient clinical rationale to grant a formulary exception. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Buprenorphine 5-microgram/hour patch prescribed for age-related osteoporosis without current pathological fracture and severe low back pain. 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 did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Buprenorphine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 100 milligram tablet prescribed for obstructive sleep apnea and fatigue. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked the 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 medication. We did not receive the documentation requested. The documentation show Modafinil was prescribed to treat obstructive sleep apnea and fatigue.Ther 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 Modafinil. 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 Orencia Clickject 125 milligram/milliliter prescribed for rheumatoid arthritis. The case was auto-forwarded by the plan.  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. The information provided indicates Orencia Clickject 125 milligram/milliliter is prescribed for rheumatoid arthritis. However, the plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records do not support the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Orencia Clickject. 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 Braftovi 75 milligram capsules prescribed for Langerhans histiocytosis. 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 the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There were no Medicare-approved peer-reviewed journal articles submitted to support the use of the requested drug 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 Xeljanz 5 milligram tablets prescribed for unspecified alopecia areata. 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 Xeljanz to treat the enrollees diagnosis of unspecified alopecia areata. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclophosphamide 25 milligram capsule prescribed for other encephalitis, encephalomyelitis and lung cancer. 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 eligible for coverage under Medicare Part B. Certain oral anticancer drugs are covered under the oral anticancer drug benefit, Social Security Act Section 1861(s)(2)(Q). We determined that the plan is not required to cover Cyclophosphamide 25 milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Prograf 0.5 milligram per milliliter compounded suspension prescribed for immunosuppressive therapy due to history of heart transplant in an enrollee with hemiplegia, dysphagia, and dementia. 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. Medicare Part D provides coverage for compounded medications when the individual ingredients can be covered by Part D. One or more of the ingredients within the requested compounded medication belongs to a class of drugs that the plan does not include in their Part D coverage when part of a compound. Because of this exclusion from coverage, the requested compounded drug is not eligible for Medicare Part D coverage. 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 Oxycontin 30 milligram ER 12 hour abuse deterrent tablet  prescribed as directed for chronic pain 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. 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. A physician reviewed your appeal and determined that the plan is not required to cover Oxycontin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5-milligram tablets prescribed for velo-cardio-facial syndrome. The 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 the drug at issue for the enrollees noted condition. 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

You requested Sirolimus powder prescribed for tuberous sclerosis. 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. This drug is a bulk powder and does not satisfy the definition of a Part D drug. 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.A physician reviewed your appeal and determined that the plan is not required to cover the Sirolimus powder.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tymlos 80 microgram pen injector prescribed for postmenopausal patient with osteoporosis. 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. The provider indicates Tymlos is prescribed to help slow the disease process and Calcitonin will be discontinued once Tymlos is approved. The prescriber also indicates that due to acute fractures and recent kyphoplasty, any medications that will reduce or lower the bone turnover including oral or intravenous bisphosphonate or Prolia cannot be given. The medical records submitted support vertebral fractures and osteoporosis with current pathological fracture, unspecified osteoporosis type. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided support the plans coverage criteria have been met.A physician reviewed your appeal and determined that the plan is required to cover Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Valsartan 40 milligram tablets prescribed for the treatment of hypertension. 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. Valsartan is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient patient specific clinical rationale as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. The prescriber has noted that the enrollee is unable to try the suggested formulary alternative drugs, Irbesartan, Losartan, and Telmisartan, because the enrollee has a history of hyperkalemia, which can be exasperated by these drugs. However, it is noted that Valsartan acts the same as the suggested formulary alternatives and may also exasperate hyperkalemia. Therefore, this is not sufficient clinical rationale to grant a formulary exception. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lynparza 150 milligram tablets prescribed for endometrial 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.The submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There were no Medicare-approved peer-reviewed journal articles submitted to support the use of the drug for the noted 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 Spravato 84-milligram tablets prescribed for major depressive disorder. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The drug at issue is only available as a direct shipment to the prescribers office. This drug is not eligible for pharmacy pick-up. 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 Corlanor 5 milligram tablets prescribed for symptomatic inappropriate sinus tachycardia. 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 Corlanor to treat the enrollees diagnosis of symptomatic inappropriate sinus tachycardia. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Corlanor.