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

At issue is a tiering exception request for Cinacalcet HCL 30 milligram tablets to treat the enrollees condition. 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.Cinacalcet HCL is a generic drug on Tier 4 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: Unfavorable

At issue is Solifenacin Succinate 10 milligram tablets prescribed daily for nocturia. You requested that the plan provide a tiering exception for this drug. The plan did not make a decision within the required timeframe. We received an auto-forwarded reconsideration request from the plan.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. Solifenacin Succinate is a generic drug on Tier 3 of the plans formulary. There are no generic 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 a tiering exception request for Flecainide Acetate, 50 milligram tablets to treat the enrollees condition.   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.Flecainide Acetate, 50 milligram tablets is a generic drug on Tier 3 of the plans formulary. There are no 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 Clonidine HCl 0.1 milligram tablets prescribed three daily for anxiety disorder and autism. The Part D plan denied your request because the documentation did not support an off-formulary exception, and 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 Clonidine HCl for anxiety disorder and autism. 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 formulary exception cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover Clonidine HCl.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Benztropine Mesylate 1 milligram tablet prescribed for primary insomnia; schizophrenia, unspecified; unspecified psychosis not due to a substance or known physiological condition. 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 Benztropine Mesylate for primary insomnia; schizophrenia, unspecified; unspecified psychosis not due to a substance or known physiological condition. In the request for reconsideration, the prescriber changed the diagnosis to tardive dyskinesis with psychosis.  Relevant medical records to support the appeal were requested but not provided. 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

You requested Lyrica 100 milligram tablets prescribed for hemicrania continua and cranial neuralgia. 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 Lyrica for hemicrania continua and cranial neuralgia. 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 Azathioprone prescribed for an unknown diagnosis. The Part D plan denied coverage because the prior authorization criteria were not met. 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. The prescriber was asked to state the diagnosis since the diagnosis was not contained within the appeal. The prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the plans prior authorization criteria. A response from the prescriber was not received. Therefore, based upon the current record, 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 Myrbetriq ER 25 milligram tablets prescribed daily for the enrollees condition. The Part D plan denied your request for a tiering exception because the prescriber did not address all alternatives were tried and failed. 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.Myrbetriq ER 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

You requested Pentazocine-Naloxone Hydrochloride, 50/.05 milligram tablets. The Part D plan denied your request because the record did not include your diagnosis. Therefore, it was not possible to determine if you had a Food and Drug Administration-approved indication for the drug. We received an expedited auto-forwarded reconsideration request from the coverage level. 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. Medical records were requested from your prescribing physician during this review, but not received.A physician reviewed your appeal and determined that the plan is not required to cover the Pentazocine-Naloxone Hydrochloride. The Part D plan is responsible for ensuring that covered Part D drugs are prescribed for medically accepted indications. The submitted documentation does not include any medical records from your physician stating what condition your medication is being prescribed for. Therefore, there is insufficient information to determine if the Pentazocine-Naloxone Hydrochloride is being prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 100 milligram tablets to treat traumatic brain injury and chronic headaches. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jakafi 10 milligram to treat chronic myelomonocytic leukemia.  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 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Quetiapine Fumarate 150 milligrams to treat F33.1, Major depressive disorder, recurrent, moderate.  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 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

You requested Tacrolimus 1 milligram capsules prescribed following a kidney transplant. The Part D plan denied the request because drugs that could be covered under Medicare Part A or Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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 record shows the physician prescribed Tacrolimus for the prevention of organ rejection after a kidney transplant. Medicare records show that this transplant was covered by Medicare Part A. Drugs used for immunosuppressive therapy following a Medicare covered transplant are eligible for coverage under Medicare Part B. Therefore, this drug is not eligible for Medicare Part D coverage.We determined that the plan is not required to cover Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitriol 0.25 milligrams prescribed once a day for unknown diagnosis. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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 record shows the enrollee is receiving dialysis. The Calcitriol should be paid under the dialysis bundle under Medicare Part B. We determined that the plan is not required to cover Calcitriol. The drug is eligible for coverage by your Part B plan; therefore, it is not eligible under your Part D plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle Libre 14 Day Sensor prescribed for your diabetes. Upon review, the Part D plan denied coverage because the Freestyle Libre 14 Day Sensor  is a medical supply that is specifically excluded from Part D coverage by Medicare law. Subsequently, the Part D Qualified Independent Contractor (QIC) received an expedited request from the appellant to reconsider the appeal. 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. In this instance, the QIC has determined that coverage cannot be allowed for the Freestyle Libre 14 Day Sensor because the plan does not cover drugs/items excluded from Medicare Part D coverage. Medicare rules state that the definition of a Part D drug includes medical supplies directly associated with the injection of insulin. Test strips, lancets, and needle disposal systems are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. Therefore, the plan is not required to provide coverage for the Freestyle Libre 14 Day Sensor. If the enrollee purchases drugs/items that are excluded, they must pay for them themselves. This decision does not address the medical necessity or appropriateness of the requested item. It only establishes that payment cannot be made under the Medicare Part D benefit.We determined that the plan is not required to cover the Freestyle Libre 14 Day Sensor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 10 milligram capsules prescribed as directed for chronic nausea related to chronic intractable headaches. The Part D plan denied your request 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 Dronabinol for chronic nausea related to chronic intractable headaches. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Balsalazide Disodium 750 milligram capsule prescribed three times daily to treat ulcerative proctitis. The Part D plan denied the request for a tiering exception. 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.Balsalazide Disodium is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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 Zonisamide 100 milligram capsules prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other drugs on a lower cost-sharing tier to treat your condition. 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.Zonisamide is a generic drug on Tier 2 of the plans formulary. There are no other drugs of the same type on the lower cost sharing tiers to treat your 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 Clobazam 10 milligram tablets to treat refractory epilepsy.  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 following citation in Micromedex, a Medicare approved compendium, supports the use of the requested drug for your condition:  Adjunctive therapy with clobazam has been effective in the treatment of uncontrolled or refractory epilepsy in adults and children (Robertson, 1986; Scott & Moffett, 1986; Tinuper et al, 1986; Aucamp, 1985; Allen et al, 1983; Franceschi et al, 1983; Shimizu et al, 1982. Therefore, it is considered a medically accepted indication.In addition, the prescriber has indicated why all alternatives required by the plan would likely not be as effective as the requested drug for you, or would likely cause adverse reaction(s). Therefore, an exception to the plans coverage criteria is medically necessary.However, the plan limits the amount of Clobazam 10 milligram tablets to 60 tablets per 30 days. The prescriber is requesting 90 tabs per 30 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. The prescriber has not addressed alternative drug strengths available on the formulary. Therefore, an exception to the plans quantity limit 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 Prolastin-C 1000 milligram/20 milliliter intravenous prescribed for the enrollees alpha-1-antitrypsin deficiency. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription biologics. If prior approval is not obtained, the plan may not cover the biologic. 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. A request was submitted to the prescriber to address the prior authorization criteria, and to provide supporting medical records. The documentations received support the drug was prescribed for the enrollees diagnosis of alpha-1-antitrypsin deficiency. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colcrys 0.6 milligram tablet (45 tablets per 90 days) 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 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 formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz XR Tablet ER 24 hour to treat inflammatory bowel disease, arthritis, ankylosing spondylitis. 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 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 Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dexmethylphenidate ER 20 milligrams tablet prescribed as directed for narcolepsy. The case was auto forwarded by the plan.   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 record shows you were prescribed Dexmethylphenidate to treat your condition. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Dexmethylphenidate because it was not prescribed for a medically accepted indication.