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

At issue is Tretinoin Cream 0.05% prescribed for anti-aging, fine lines, and wrinkles. 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. The prescribers office indicates the drug is requested for acne vulgaris or actinic keratosis. We requested additional information, medical records, from the prescriber to confirm a diagnosis but did not get a response. In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, documentation supporting a medically accepted indication are required. The information was insufficient to determine medical necessity and if the drug is eligible for coverage under Part D benefits. A physician reviewed your appeal and determined that the plan is not required to cover Tretinoin Cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Candesartan Cilexetil 32 milligram tablets prescribed for hypertension. 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. 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 the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Candesartan Cilexetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 20 milligram tablet prescribed once daily. 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. Xarelto 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

The enrollee requested Gleostine 40 milligram capsule prescribed for glioblastoma. 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. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the list, the manufacturer, Nextsource Biotechnology, LLC, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Gleostine. 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 Glassia 60-milligrams/kilogram (+/-10%) Intravenous Solution to treat Alpha-1-antitrypsin deficiency. 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 the diagnosis of mild/early emphysema was given. 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 support that the enrollee has a medically accepted indication. Furthermore, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria. 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 Mesalamine delayed-release 1.2 gram tablets. The Part D plan denied the appeal request for a tiering exception.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.Mesalamine is a generic drug on Tier 4 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat the enrollees condition have been tried or deemed contraindicated. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5-milligram tablet to treat atrial fibrillation. 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. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sildenafil Citrate 20 milligram tablets, 270 tablets per 30 days. The Part D plan denied the request because the plans prior authorization requirements were not met. Additionally, the amount requested exceeded the plans quantity limit of 90 tablets per 30-day supply.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 Sildenafil Citrate has been prescribed for the treatment of pulmonary hypertension, World Health Organization (WHO) group 2. However, the Medicare approved compendia do not contain any citations to support the use of 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. Since the drug is not eligible for coverage, the plans prior authorization and quantity limit requirements are not relevant to this review. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 50 milligram capsules prescribed for hip pain and sciatica. 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 submitted documentation indicates the prescriber ordered Pregabalin for hip pain and sciatica. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrocortisone-Pramoxine 2.5% - 1% cream prescribed for rectal pain. 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. The record shows the Hydrocortisone-Pramoxine cream is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover Hydrocortisone-Pramoxine cream. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligram/milliliter solution prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.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.Prolia is a biologic on Tier 4 of the plans formulary. There are no biologics of the same type on the lower cost sharing tiers. Therefore, this biologic is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patches prescribed for abdominal pain due to a liver mass. 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.We requested additional documentation related to this case. Specifically, we asked the prescriber to submit medical records to support a covered diagnosis and a prescriber statement. We received the requested information and included it in the review.The submitted documentation indicates the prescriber ordered Lidocaine for abdominal pain due to a liver mass. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humalog Kwikpen 100-units/milliliter Solution Pen-Injector to treat 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. Humalog is a brand drug on Tier 2 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 Edarbyclor 40 mg-25mg tablet prescribed as directed for hypertension. 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 Edarbyclor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Cosentyx Sensoready 150 milligram/milliliter injection prescribed for psoriatic arthritis. The Part D plan denied coverage.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 records submitted at the reconsideration level. The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.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 Corlanor 5-milligram tablet to treat congestive heart failure, tachycardia, and palpitations. 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.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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 200-milligrams/1.14-milliliter Syringe to treat 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 information 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 show the enrollee has satisfied the plan's coverage criteria. 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 tiering exception request for Jardiance 10 milligram tablets. 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. The medical records indicate that Jardiance has been prescribed for the treatment of type 1.5 diabetes. However, the Medicare approved compendia do not contain any citations to support the use of Jardiance for the treatment of the noted condition. Although the drug is being used for a non-medically accepted indication, the plan has approved coverage of the Jardiance, which is on Tier 3 of the plans formulary. However, a tiering exception will not be granted by the plan for a drug that is being used for an indication that is not cited in the Medicare approved compendia. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier. The drug will continue to be covered at the Tier 3 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Esterified Estrogen-Methyltest 0.625/1.25 milligram tablet prescribed for post menopausal symptoms. 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. The prescriber requests Esterified Estrogen-Methyltest 0.625/1.25 milligram tablet to treat symptoms due to post menopause. However, Medicare does not cover Drug Efficacy Study Implementation drugs. These drugs are not considered a Part D eligible drug.A physician reviewed your appeal and determined that the plan is not required to cover Esterified Estrogen-Methyltest 0.625/1.25 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 25 microgram tablets prescribed as directed for hypothyroidism. 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 Synthroid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Tadalafil 20 milligram tablets. The Part D plan denied the request for coverage because the medication was being used for a non-medically accepted indication. 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 medical records initially submitted to the plan indicate that Tadalafil was prescribed for pulmonary hypertension, World Health Organization, group 3. However, the Medicare approved compendia do not contain any citations to support the use of Tadalafil for the treatment of this condition.The diagnosis provided at reconsideration is pulmonary hypertension, World Health Organization, group 5. However, the Medicare approved compendia do not contain any citations to support the use of Tadalafil for the treatment of this condition.Therefore, the requested drug is being prescribed for non-medically accepted indication(s). As such, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% Patch to treat radiculopathy, lumbosacral region and cervicalgia. 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 Diclofenac Epolamine to treat your radiculopathy, lumbosacral region and cervicalgia. However, the Medicare approved compendia do not support the use of this drug for your condition. 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 tiering exception request for Myrbetriq 50 milligram extended release tablets prescribed for overactive bladder. 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. Myrbetriq is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level. The drug will continue to be covered at the Tier 4 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 8 milligram sublingual tablets prescribed for osteoarthritis of thoracic spine with radiculopathy and thoracic radiculitis. 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 submitted documentation indicates the prescriber ordered Buprenorphine Hydrochloride sublingual tablets for osteoarthritis of thoracic spine with radiculopathy and thoracic radiculitis. The Medicare approved compendia do not support the use of the drug at issue, in sublingual tablet formulation, for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 10-20-30-milligram Tablet DS Pak to treat moderate to severe plaque psoriasis. 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.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 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 Mofetil 500-milligram tablet to treat cicatricial pemphigoid. 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 Mycophenolate Mofetil to treat your cicatricial pemphigoid. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.