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

At issue is a request for coverage of Nuedexta 20-10 milligram capsules. 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 indicates that Nuedexta has been prescribed for the treatment of pseudobulbar affect. The use of Nuedexta has been approved by the Food and Drug Administration for the treatment of pseudobulbar affect. Therefore, the medication is being prescribed for a medically accepted indication.  However, the plan has prior authorization requirements that have to be satisfied before covering Nuedexta. During this review, a request was submitted to the prescriber to address the plans coverage criteria for the medication and to provide supporting medical records. However, the prescriber did not respond to the request. The submitted 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 Xywav 0.5-milligrams/milliliter to treat narcolepsy type 1 (narcolepsy with cataplexy. 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 Januvia 50 milligram tablets prescribed for diabetes. 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. Januvia 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 febuxostat 40-milligram tablet to treat gout. 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 prescriber has indicated why all alternatives required by the plan would likely not be as effective as the requested drug. Therefore, an exception to the plans coverage criteria is medically necessary. Our physician reviewer's opinion is that step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent pen injector 300 milligram/2 milliliter prescribed for atopic dermatitis. 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 plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not include medical records to 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 Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide Extended-Release 9 milligram tablet prescribed daily for ulcerative colitis. 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 prescribed Budesonide to treat your ulcerative colitis. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Treatment with once daily Budesonide 9 milligram oral extended-release tablets resulted in a significantly greater remission rate for active, mild to moderate ulcerative colitis.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 Budesonide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate Hydrochloride 10 milligram tablets. 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. Methylphenidate Hydrochloride is a generic drug on Tier 4 of the plans formulary. We requested additional information from your prescriber but did not get a response. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you. 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 Repatha Sureclick 140 milligram/milliliter auto-Injector prescribed to treat hyperlipidemia in a patient with clinical atherosclerotic cardiovascular 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 records submitted at the reconsideration level. At reconsideration, Repatha Sureclick 140 milligram/milliliter auto-Injector was prescribed to treat hyperlipidemia in a patient with clinical atherosclerotic cardiovascular disease. Medical records provided do not validate that this patient has clinically significant atherosclerotic cardiovascular disease. It is not indicated that enrollee has/had angina, myocardial infarction, acute coronary syndrome, CVA/TIA, peripheral arterial disease, or previous coronary revascularization. It is indicated that a July, 2020, stress test was unremarkable, with above average exercise tolerance. Additionally, although joint pain is reported with statins, no muscular complaints or significant physical exam findings are documented. The plans prior authorization criteria have not been satisfied.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 Ingrezza 40-milligram Capsule to treat drug subacute tardive dyskinesia. 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 Lantus 100 unit/milliliter solution prescribed for type 1 diabetes with hyperglycemia. 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

You requested Amlodipine besylate 10 milligram tablets prescribed for unknown diagnosis. The Part D Plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Medicare rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. The record shows you are eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered and paid by a Veteran Affairs benefit. We determined that the Part D plan is not required to reimburse you for the Amlodipine besylate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Atenolol 50 milligram tablets prescribed for unknown diagnosis. The Part D Plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Medicare rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. The record shows you are eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered and paid by a Veteran Affairs benefit. We determined that the Part D plan is not required to reimburse you for the Atenolol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clopidogrel bisulfate 75 milligram tablets prescribed for unknown diagnosis. The Part D Plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Medicare rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. The record shows you are eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered and paid by a Veteran Affairs benefit. We determined that the Part D plan is not required to reimburse you for the Clopidogrel bisulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rosuvastatin calcium 40 milligram tablets prescribed for unknown diagnosis. The Part D Plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Medicare rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. The record shows you are eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered and paid by a Veteran Affairs benefit. We determined that the Part D plan is not required to reimburse you for the Rosuvastatin calcium.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Terazosin hydrochloride 2 milligram capsules prescribed for unknown diagnosis. The Part D Plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Medicare rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. The record shows you are eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered and paid by a Veteran Affairs benefit. We determined that the Part D plan is not required to reimburse you for the Terazosin hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Perforomist 20 micrgram/2 milliliter vial 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. The record shows Perforomist is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Perforomist. Please submit your request to Medicare Part B. 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

At issue is Tymlos 3.12 milligrams/1.56 milliliter solution prescribed for osteopenia. 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 your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received some of the documentation requested and included it in our review.  Medical records were not provided. The prescriber statement shows you prescribed Tymlos to treat the enrollees osteopenia. 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 Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Nucynta 50 milligram ER tablets prescribed for radiculopathy, lumbar region. 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. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Nucynta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ingrezza 40 milligram capsules prescribed for bipolar disorder. 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 prescriber indicates Ingrezza is prescribed for bipolar disorder. However, 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 Ingrezza.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Invokamet 150-1000 milligram tablets. 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 does not include a supporting statement or medical records. A request was sent to your physician for medical records and a supporting statement, but no documentation was received. The documentation indicates the drug was prescribed for diabetes mellitus; however, without medical records or a supporting statement, 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

At issue is Octagam 25-grams/500-milliliters. At initial determination and redetermination the diagnoses of polyneuropathy (G62.9), other specified diseases of the digestive system (K92.89), and disorder of the autonomic nervous system, unspecified (G90.0) were given. The Part D plan denied the request stating that the provided diagnoses were non-medically accepted indications. 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 the diagnoses of small fiber neuropathy (G62.9), autoimmune gastrointestinal dysmotility (K92.89), Ehlers-Danlos syndromes (Q79.6), dysautonomia (G90.9), pan-GI dysmotility (K22.4), POTS (149.8), and autoimmune autonomic neuropathy were added. The use of the requested drug to treat the provided diagnoses are off-label uses. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jadenu 360 milligram tablet, a quantity of 90 tablets per 30 days prescribed for hemosiderosis (chronic iron overload) secondary to multiple red blood cell transfusions. 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 Jadenu to treat your hemosiderosis (chronic iron overload) secondary to multiple red blood cell transfusions. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The enrollee is known to have low platelet counts. This drug is contraindicated in patients with low platelet counts. The prescriber does not detail or discuss this issue in the provided records. 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 Jadenu.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 3% gel for primary osteoarthritis of the right knee. 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. We also 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.The use of the requested drug dosage, as 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 your 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 Diclofenac Sodium 3% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Atrevis Hydrogel. The Part D plan denied your 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 determined that the plan is not required to cover Atrevis Hydrogel because the compounded medication includes ingredients that are over the counter drug products. Nonprescription or over-the-counter drugs are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.