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

At issue is Repatha solution prefilled syringe 140 milligram/milliliter prescribed for hyperlipidemia and atherosclerotic heart disease of native coronary artery without angina pectoris. 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. Your doctor submitted a statement that shows Repatha was prescribed for hyperlipidemia and atherosclerotic heart disease of native coronary artery without angina pectoris. 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 documentation does 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 225 milligram capsule prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. Your 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 Pregabalin. 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 Anoro Ellipta 62.5-25 microgram inhaler 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. Your doctor submitted a statement that shows Anoro Ellipta was prescribed for chronic obstructive pulmonary disease. 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 documentation does 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 Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 8 milligram sublingual tablet.  At initial determination and redetermination the diagnosis of lumbago with sciatica and cervical disc degeneration was given. The Part D plan denied the request stating that the provided diagnoses are non-medically accepted indications.  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 opioid use disorder 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus 100 unit/milliliter vial prescribed for the enrollees condition. 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. Lantus 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. 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 Pregabalin 150 milligram capsule prescribed twice daily for neck pain. 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. Your medical records show your doctor prescribed Pregabalin to treat your neck pain. Your 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 Pregabalin. 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 Coenzyme Q 10 100% Powder prescribed for mitochondrial myopathy, antiphospholipid syndrome, and methylenetetrahydrofolate reductase deficiency. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and reviewed the enrollment data available. Bulk powders are not approved by the food and drug administration and are therefore not covered under Part D.A physician reviewed your appeal and determined that the plan is not required to cover Coenzyme Q 10 100% Powder.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ambrisentan 5 milligram tablet for pulmonary arterial hypertension WHO Group 4, chronic thromboembolic pulmonary hypertension, and idiopathic pulmonary fibrosis. 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 Ambrisentan to treat pulmonary arterial hypertension Group 4, chronic thromboembolic pulmonary hypertension, and idiopathic pulmonary fibrosis. 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 Ambrisentan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levemir 100 unit/milliliter vial prescribed for Type 1 diabetes mellitus. 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. Levemir 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 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 Metaxalone 800 milligram tablet prescribed three times daily for muscle spasms. We received an auto-forwarded reconsideration request from the coverage level.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes 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. The prescriber states that no formulary alternatives have been tried.A physician reviewed your appeal and determined that the plan is not required to cover Metaxalone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 50 milligram capsule prescribed twice daily for back pain. 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. Your medical records show your doctor prescribed Pregabalin to treat your back pain. Your 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 Pregabalin. 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 Eliquis 5 milligram tablets prescribed for the enrollees condition. 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 provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed 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 Fasenra Pen Auto-injector 30 milligram/milliliter solution prescribed for moderate persistent asthma with recurrent exacerbations. 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.Your medical records show your doctor prescribed Fasenra Pen Auto-injector to treat your moderate persistent asthma with recurrent exacerbations. 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 Fasenra Pen Auto-injector.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Accu-Chek Aviva Plus Test Strips prescribed for monitoring your blood glucose levels. 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. Your medical record shows that you are a person with diabetes. Glucose monitoring supplies (test strips) are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Medicare Part D. As such, the Accu-Chek Aviva Plus Test Strips are excluded from Part D coverage by Medicare law.We have determined that your plan is not required to cover Accu-Chek Aviva Plus Test Strips. Medicare Part B/Durable Medical Equipment is responsible.
Appeal type: Prescription Drug
Decision: Unfavorable

Your medical records show your doctor prescribed Buprenorphine Hydrochloride 8 milligram sublingual tablets to treat chronic pain syndrome, lower leg pain, and other chronic pancreatitis. 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, in the formulation prescribed, 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, as ordered, is not being used for a medically accepted indication. The requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Enbrel 50 milligram per milliliter subcutaneous injection syringe, 12 milliliters per 90 days, prescribed for psoriatic arthritis. The Part D plan approved coverage for the Enbrel 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 prescriber has requested 50 grams of Enbrel to be injected weekly, which would be 1 milliliter per week and 12 milliliters for 12 weeks (90-day supply) of the drug. However, Enbrel is included in the Specialty Tier (Tier 5) of the plans formulary. Drugs in the Specialty Tier are limited to a recurring 30-day supply. In this case, Enbrel is limited to 4 milliliters per 28 days recurring monthly. 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 a 90-day supply of Enbrel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Scopolamine 72 hour Transdermal Patch 1 milligram. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your prescriber indicates the medication is required for post-op nausea. We asked your prescriber to send us information regarding your condition and medical records to support the diagnosis reported. The prescriber did not respond to a request for addition information. It was unable to be determined if the drug was medically necessary and medically indicated for your condition.  A physician reviewed your appeal and determined that the plan is not required to cover Scopolamine Transdermal Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz XR 11 milligram tablets prescribed for Crohns disease of large intestine with other complications. 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 Xeljanz XR to treat your Crohns disease of large intestine with other complications. 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 Xeljanz XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dextroamphetamine-Amphetamine Extended Release 15-milligram tablets, 6 capsules/day, to treat narcolepsy. 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.At issue is Dextroamphetamine-Amphetamine Extended Release 15-milligram tablets, 6 capsules/day (180 capsules/30 days), to treat narcolepsy. The plan limits the amount of Dextroamphetamine-Amphetamine Extended Release, 15 mg capsules, to 30 capsules/30 days. The prescriber has not indicated why other formulations (strengths) available on the formulary (including higher strengths with higher quantity limits), could not be used in this enrollee. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Dexilant 60-milligram Capsule Delayed Release to treat the enrollees gastroesophageal reflux disease without esophagitis. 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.Dexilant 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 Pregabalin 50-milligram tablet to treat an unknown diagnosis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.At reconsideration a diagnosis of peripheral neuropathic pain related to history of carcinoma was given. However, the documentation does not satisfy the plans coverage criteria. The prescriber has not addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug. 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 Travatan Z 0.004% eye drops prescribed for open angle glaucoma (increased intraocular pressure). 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. Your prescriber indicates you have tried Latanoprost, Dorzolamide/Timodol, and Bimatoprost. However, there is no supporting evidence that all the plans formulary, alternative drugs, have been tried.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 Travatan Z eye drops.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligram tablet prescribed three times daily for right heart failure. 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 Sildenafil Citrate to treat the enrollees right heart failure. 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 Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nulojix 525 milligram intravenous solution prescribed monthly for kidney transplant rejection prophylaxis. 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 record shows the enrollee was prescribed Nulojix following a Medicare covered kidney transplant on January 14, 2011. Therefore, the drugs is eligible for coverage under Medicare Part B and excluded from Part D coverage.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.We determined that the plan is not required to cover Nulojix.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550-milligram tablet to treat small intestinal bacteria overgrowth. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.