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

You requested Nuzyra 100 milligram solution for mycobacterium chelonae abscesses. 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 Nuzyra 100 milligram solution for mycobacterium chelonae abscesses. 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 Nuzyra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tygacil 50 milligram powder for solution prescribed for cutaneous mycobacterial infection. 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 Tygacil to treat the enrollees mycobacterial cutaneous infection. However, the Medicare approved compendia do not support the use of this drug for this type of cutaneous infection. A physician reviewed your appeal and determined that the plan is not required to cover Tygacil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Afrezza 4 unit/8 unit/12 unit insulin inhalation powder prescribed for type 2 diabetes. The Part D plan approved a non-formulary exception for the Afrezza but denied the request for a 90-day supply of the medication.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 has approved coverage for the Afrezza, which is not included on the plans formulary. The prescriber has requested a 90-day supply of the drug; however, the plan limits non-formulary drugs to a recurring 30-day supply. Specifically, Afrezza is limited to 180 cartridges per 30 days. An exception to the quantity limit criteria has not been met. A physician reviewed the appeal and determined that the plan is not required to cover more than 180 cartridges of Afrezza per 30 days.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nexletol 180 milligram tablet for hypertensive heart disease without heart failure, nonrheumatic aortic (valve) stenosis and mixed 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 information submitted at the reconsideration level. The documentation shows your doctor prescribed Nexletol for hypertensive heart disease without heart failure, non rheumatic aortic (valve) stenosis and mixed hyperlipidemia. 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 Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide EC 3 milligram capsules prescribed for eosinophilic gastritis. 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 records show you prescribed Budesonide EC 3 milligram capsules to treat the enrollees eosinophilic gastritis. 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 Budesonide EC 3 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rydapt 25 milligram capsules prescribed for acute myeloblastic leukemia and proliferative myelodysplastic syndrome. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The records show you prescribed Rydapt 25 milligram capsules to treat the enrollees acute myeloblastic leukemia and proliferative myelodysplastic syndrome. 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 Rydapt 25 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nulojix 250 milligram vial 2/28 prescribed to prevent kidney transplant rejection. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the enrollee had a kidney transplant on November 7, 2020. According to Medicare enrollment records, the enrollee was entitled to Medicare Part A coverage at the time of the transplant. Therefore, the transplant is considered a Medicare covered transplant and Nulojix is eligible for coverage under Medicare Part B. Medicare Part B covers prescription drugs used in immunosuppressive therapy furnished to an enrollee who has received an organ transplant. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. We determined that the Medicare Part D plan is not required to cover Nulojix. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Creon 24,000 units/capsule prescribed 1-2 capsules with meals to treat pancreatic insufficiency. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Creon is a biologic drug on Tier 3 of the plans formulary. There are no biologic 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 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 Mycophenolate Mofetil 500 milligram tablet prescribed twice daily for Sjogrens syndrome and mononeuritis multiplex. 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 Mycophenolate Mofetil to treat the enrollees Sjogrens syndrome and mononeuritis multiplex. However, the Medicare approved compendia do not support the use of this drug for these conditions.A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bisoprolol-Hydrochlorothiazide 1.5-6.25 milligram tablets prescribed to treat hypertension.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 Bisoprolol-Hydrochlorothiazide 1.5-6.25 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta prescribed for chronic obstructive pulmonary disease. 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 all 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 Trelegy Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tirosint-Sol 200 micrograms per milliliter, 1 milliliter by mouth every day for primary hypothyroidism. 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.We asked the 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 other medications on the plan's formulary would not work for you. 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, the medical records do not support why other drugs on the plans formulary would not work. A physician reviewed the appeal and determined that the plan is not required to cover Tirosint-Sol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Repatha SureClick 140 milligram per milliliter subcutaneous injection pen. 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 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 medical records indicate that Repatha SureClick has been prescribed for the treatment of mixed hyperlipidemia. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Repatha SureClick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram/milliliter solution auto-injector prescribed every two weeks for 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 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 Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 micrograms per actuation for centrilobular emphysema. 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.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 medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. 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, the medical records do not support why other drugs on the plans formulary would not work. A physician reviewed the appeal and determined that the plan is not required to cover Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is First Omeprazole 2-milligrams/milliliter Suspension to treat gastroesophageal reflux disease without esophagitis. 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.Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.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 Testosterone 1.62% (1.25 gram) Packet prescribed for hypogonadism. 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 Testosterone 1.62% to treat your hypogonadism. However, the Medicare approved compendia do not support the use of this drug for your condition due to not being related to testicular failure due to/caused by cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome, orchiectomy, Klinefelters syndrome, chemotherapy, or toxic damage from alcohol or heavy metals. A physician reviewed your appeal and determined that the plan is not required to cover Testosterone 1.62%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10-milligram tablet to treat psychophysiologic insomnia. 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed, with support of medical records, the issues regarding this high-risk medication, and why alternative safer medications, in the plan's formulary, could not be used.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 a request for coverage of Tymlos 3120 microgram per 1.56 milliliter subcutaneous injection pen. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Tymlos has been prescribed for osteoporosis not related to menopause. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vraylar 1.5 milligram capsules prescribed for persistent depressive disorder. 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.The submitted documentation indicates your doctor prescribed Vraylar for persistent depressive disorder. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As it cannot be determined that the drug was 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

You requested First Lansoprazole 3 microgram/3 milliliter suspension 300 for 30 days prescribed for the treatment of cancer. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.According to the Food and Drug Administration, First Lansoprazole suspension is not an approved drug. Therefore, we determined the plan is not required to cover the First Lansoprazole suspension. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate 2.5 milligram/3 milliliter nebulizer solution prescribed for chronic obstructive pulmonary disease. 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 submitted documentation indicates the drug at issue is to be used in a nebulizer in the enrollees home. This is eligible for coverage under Part B. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Albuterol Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 40 milligram tablets prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Latuda is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Hydroxyzine Hydrochloride 25 milligram tablets prescribed for generalized anxiety disorder. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Sodium 180-millligram tablet for prophylaxis against liver transplant rejection. 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 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 formulary coverage criteria is not supported.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Saxenda Pen 18 milligram/3 milliliter. The Part D plan denied your request as the drug was being used for weight loss and drugs used for weight loss are excluded from Medicare Part D 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your prescriber indicates Saxenda is prescribed for hyperglycemia and not for weight loss. However, Medicare approved compendia do not support the use of this drug for this condition as there is no supporting evidence of Type 2 diabetes mellitus. A physician reviewed your appeal and determined that the plan is not required to cover Saxenda.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin 20 milligram tablet prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is not included on your plans formulary. 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 grant your request for a tiering exception.