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

At issue is Proair Digihaler 90 micrograms/actuation to treat asthma. 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 records show that the doctor prescribed Proair Digihaler for your asthma. Proair Digihaler 90 micrograms/actuation is not on the plan's formulary. 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. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewer's opinion is that the plan is not required to cover Proair Digihaler because formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Enoxaparin sodium 120 milligram/ 0.8 milliliter injections prescribed every 12 hours for paroxysmal atrial fibrillation. The Part D plan denied your request for a quantity limit exception because the 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 documentation shows the doctor prescribed Enoxaparin sodium for paroxysmal atrial fibrillation. The physician states that the enrollee had two strokes, of suspected embolic origin, while taking other anticoagulant medications. However, the Medicare approved compendia do not support the use of Enoxaparin sodium for the enrollees condition. Therefore, the request for a quantity limit exception cannot be granted.A physician reviewed your appeal and determined that the plan is not required to cover Enoxaparin sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aranesp 25 microgram/0.42 milliliter injection prescribed for anemia in chronic kidney disease. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Aranesp.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets prescribed twice times daily for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. 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.Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% Gel Pump.  At initial determination and redetermination the diagnosis of hypoactive sexual desire disorder was given. The Part D plan denied the request stating that drugs prescribed to treat sexual dysfunction do not meet the definition of Part D drugs.  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.At reconsideration a diagnosis of erosive vulvar lichen planus was given. No medical records were provided by the prescriber to support this diagnosis. 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. 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 Risperidone 1 milligram prescribed for dementia related psychosis. The Part D plan denied the request. We received an expedited 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. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia do not support the use of this medication for the diagnosis submitted. Therefore, it is ineligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Deferasirox 360 milligram tablets prescribed for iron overload. The Part D plan denied the 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The prescriber stated that an imaging test showed increased signal intensity consistent with iron deposition in the hepatic parenchyma and a serum ferritin may not be a good marker of iron overload, whereas iron deposition in the liver is. The plan requires serum ferritin levels greater than 1000 micrograms per liter. 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 Deferasirox.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 2.5 milligram tablet for the diagnosis of deep vein thrombosis. 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.Eliquis 2.5 mg tablet is a brand drug on tier 2 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 Tremfya 100 milligram/milliliter syringe prescribed for plaque psoriasis vulgaris. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited 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. 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. Therefore, an exception to the plans coverage criteria is not supportedA physician reviewed your appeal and determined that the plan is not required to cover Tremfya 100 milligram/milliliter syringe because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Freestyle Libre 14 day reader device.  The Part D plan denied the request because devices that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit.  Medicare Part B covers medical supplies that are not directly related to the delivery of insulin to the body. Test strips, lancets, and needle disposal systems are included in this category.  They are covered by Medicare Part B. We received an expedited 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 requested device may be eligible for coverage under Part B under Medicare rules. A physician reviewed the appeal and determined that the requested device is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Voriconazole 200 milligram tablets to treat acute myeloid leukemia in remission, fungal prophylaxis. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received an expedited 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 your appeal and determined that the plan is not required to cover Voriconazole 200 milligram tablets because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets prescribed daily for atrial fibrillation. The Part D plan denied your request for a tiering exception. We received an expedited 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. is Eliquis 5 milligram tablets are 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 the plan is not required to cover is Eliquis 5 milligram tablets because non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Januvia 100 milligrams tablet to treat Type 2 diabetes mellitus.   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.Januvia 100 milligrams tablet is a brand drug on Tier 2 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 Valchlor gel 0.016%, quantity of 6 tubes per month prescribed for mycosis fungoides. The Part D plan denied coverage due to the quantity of the requested drug exceeding the amount allowed. We received an expedited reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The physician submitted a supporting statement. The prescriber statement indicates the enrollee has greater than 60% body surface area for mycosis fungoides.However, medical records have been submitted for review and do not substantiate the need to exceed the plans quantity limits. Therefore, the documentation available 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 Valchlor gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Spravato 84 milligrams dose pack 6 per 14 days to treat depression. 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 under a formulary exception.  Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga, 10 milligram tablets prescribed for the following conditions: coronary artery disease involving native coronary artery of native heart with unstable angina pectorism; history of coronary artery bypass graft; hypertensive heart disease; and diabetes. The Part D Plan denied your request for a tiering exception because there were no other similar drugs on a lower cost-sharing tier. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Farxiga at a lower cost tier.Farxiga 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. If there are no brand name drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. Therefore, a tiering exception cannot be granted for the Farxiga.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol 1 milligram tablets prescribed daily for postmenopausal vaginal atrophy and vasomotor symptoms. 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. We also researched Medicare systems and reviewed the enrollment data available.The records show you prescribed Estradiol to treat the enrollees postmenopausal vaginal atrophy and vasomotor symptoms. The plan requires prior authorization criteria 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 Estradiol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cimzia 200 milligrams/milliliter subcutaneous injections prescribed for moderate, active rheumatoid arthritis. The Part D plan denied your request because the documentation did not support an off-formulary exception. The Part D plan further stated if an exception is approved, the drug is not available for greater than a recurring 30-day supply. 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 prescriber statement does not show a medical reason why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Cimzia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Pregablin 100 milligram capsules prescribed three times daily to treat the enrollees condition. The Part D plan denied the request for a tiering exception. We received an expedited 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.Pregablin is a generic drug on Tier 3 of the plans formulary. There are no generic 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: Favorable

You requested Ursodiol 3600 milligrams prescribed two capsules twice daily for primary biliary cholangitis. The Part D plan approved the non-formulary exception but denied your request for the quantity being dispensed because it was an unsafe amount. 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 required to cover the Ursodiol 300 milligrams. Medicare compendia support the recommended dosage is 13-15 milligrams/kilogram a day. The enrollees weight would require four capsules (1200 milligrams) per day. The Medicare rules above have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate 10 milligram tablets prescribed daily for bipolar disorder, type I. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. 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. The medical records show Methylphenidate was originally prescribed in 2010 to treat the enrollees major depressive disorder. The enrollee was later diagnosed with type I bipolar disorder at which point Methylphenidate was continued. 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 Methylphenidate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Creon DR 36,000 unit capsules prescribed as directed for pancreatic insufficiency. The Part D Plan denied your request for a tiering 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. Creon is a biologic drug on Tier 3 of the plans formulary. There are no biologic drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Horizant 600 milligram tablets prescribed twice daily for radiculopathy, lumbar region. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. 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. The submitted documentation indicates your doctor prescribed Horizant for radiculopathy, lumbar region. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 25 milligrams.  At initial determination and redetermination the diagnosis of spondylosis without myelopathy or radiculopathy, lumbar region, was given. 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 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 doctor indicated the correct diagnoses are fibromyalgia and bladder spasms. However, the progress note shows Pregabalin was prescribed for concern of fibromyalgia. The records do not support the change in prescribing diagnosis. They do not support a medically accepted indication in accordance with the Medicare approved compendia. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.