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

At issue is Invokamet 150-1,000 milligram oral tablet prescribed daily for type II diabetes mellitus. The Part D plan denied your request for a tiering exception. 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.Invokamet 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 a tiering exception. There are no lower tiered brand drugs of the same type to treat the enrollee's condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 20 milligram tablet to treat your deep vein thrombosis and acute embolism. The Part D plan denied the request. We received an expedited 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.Xarelto 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 a tiering exception request for Budesonide EC 3 milligram capsule 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.Budesonide EC 3 milligram capsule 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

You requested Iressa 250 milligram tablets prescribed for advanced gastric adenocarcinoma with epidermal growth factor receptor and peroxisomal membrane protein 4 fusion. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The records show you prescribed Iressa 250 milligram tablets to treat the enrollees advanced gastric adenocarcinoma with epidermal growth factor receptor and peroxisomal membrane protein 4 fusion. However, the Medicare approved compendia and Medicare approved journals 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 Iressa 250 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Enestro 49/51 milligram tablets to treat chronic systolic heart failure. 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 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 a brand drug provided by the plan at the cost sharing level of Tier 3. There are no brand drugs of the same type, at a lower cost sharing tier. 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 Depo-Testosterone 200 milligrams per milliliter, 100 milligrams intramuscularly weekly, to treat cancer-related testicular hypofunction. 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 asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. We received the documentation and included it in our review.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 coverage for Imvexxy 4 microgram vaginal inserts prescribed for vaginal atrophy. 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.Imvexxy is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, 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

You requested Braftovi 75 milligram capsules prescribed as directed for the treatment of advanced squamous cell carcinoma of the lung. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the physician prescribed Braftovi, in combination with Mektovi, for the treatment of advanced squamous cell carcinoma of the lung. The physician based this drug treatment approach on the results of Guardant 360 testing. However, the Medicare approved compendia do not support the use of the requested drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Braftovi.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mektovi 15 milligram tablets prescribed as directed for the treatment of advanced squamous cell carcinoma of the lung. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the physician prescribed Mektovi, in combination with Braftovi, for the treatment of advanced squamous cell carcinoma of the lung. The physician based this drug treatment approach on the results of Guardant 360 testing. However, the Medicare approved compendia do not support the use of the requested drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Mektovi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tukysa 150 milligram tablet prescribed to treat HER2-positive, metastatic esophageal cancer with ERBB2 mutation. 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 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. A physician reviewed your appeal and determined that the plan is not required to cover Tukysa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tepmetko 225 milligram tablets prescribed as directed for metastatic non-small cell lung cancer. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We asked the prescriber to send us a supporting statement and medical records showing the medical necessity of Tepmetko. We received the documentation and included it in our review.The record shows the physician prescribed Tepmetko for the treatment of metastatic non-small cell lung cancer with MET exon 14 skipping alterations. The Medicare approved compendia support the use of the requested drug for the enrollees condition. However, the prescriber statement indicates the enrollee can use a formulary alternative. The documentation does not support a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Tepmetko.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligram/milliliter SureClick injection pen prescribed as directed for hypercholesterolemia. The Part D plan denied coverage because the prior authorization criteria were not met. 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 records submitted at the reconsideration level. The medical records show you were prescribed Repatha for hypercholesterolemia. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided do not show the plan's coverage criteria have been met. Prior use of statins is noted, medical records do not sufficiently address management, and reasons for discontinuation.A physician reviewed your appeal and determined that the plan is not required to cover the Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Cyclobenzaprine Hydrochloride 10 milligram tablets. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Cyclobenzaprine Hydrochloride has been prescribed for the management of chronic musculoskeletal pain in an enrollee with inflammatory polyarthropathy and psoriatic arthropathy. 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 the Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Methylphenidate Hydrochloride 20 milligram tablets. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Methylphenidate Hydrochloride has been prescribed for the management of decreased alertness in an enrollee with severe traumatic brain injury resulting in post-traumatic hydrocephalus and major neurocognitive disorder. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cresemba 186 milligram capsule for prophylaxis of invasive aspergillosis following stem cell transplant. 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 use of the requested drug for the prophylaxis of invasive aspergillosis 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

You requested Xeljanz XR 11 milligram tablets prescribed daily for seropositive rheumatoid arthritis. 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 also researched Medicare systems and reviewed the enrollment data available. The plan requires an intolerance or contraindication to conventional therapy before they will cover the requested drug. The prescriber has not sufficiently indicated why all alternatives required by the plan would likely cause harm or not be as effective for the enrollee as 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 Xeljanz XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem tartrate 5 milligram tablet. The Part D plan denied the request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber was asked to send medical records to support the diagnosis listed. 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 Buprenorphine 2-milligram Sublingual Tablet to treat chronic low back pain.  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 following citation in Drugdex, a Medicare approved compendium, does not support the use of the requested drug for the enrollees condition:  Buprenorphine hydrochloride sublingual tablets are not appropriate as an analgesic (off-label usage). 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a tiering exception request for Carbamazepine ER 300 milligram capsules prescribed for symptomatic epilepsy. 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.Carbamazepine ER is a generic drug on Tier 4 of the plans formulary. The prescriber has not addressed why the generic drugs of the same type on the lower tiers of the plans formulary to treat the noted condition have been tried and failed, or are contraindicated. A physician reviewed the appeal and determined that the plan is not required to cover the Carbamazepine ER at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Lidocaine-Prilocaine 2.5/2.5% cream. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Lidocaine-Prilocaine cream has been prescribed for the management of neuropathic pain secondary to the presence of chronic inflammatory demyelinating polyneuropathy and diabetic polyneuropathy. 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 the Lidocaine-Prilocaine cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Rasagiline Mesylate 1 milligram tablet prescribed for Parkinsons disease. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.Rasagiline is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated why all other 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. Provider letter is acknowledged, side effect profile of alternative drugs is similar to requested drug. 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 coverage for Lidocaine urethral/mucosal external 2% gel. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Lidocaine gel has been prescribed for the management of neuropathic pain secondary to a neurogenic bowel as a result of quadriplegia. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of neuropathic pain. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate 500 milligram tablet prescribed as directed for pseudo sac syndrome. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The record shows you were prescribed Mycophenolate for pseudo sac syndrome. 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 Mycophenolate because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch to treat dorsalgia. 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 also researched Medicare systems and reviewed the enrollment data available. The use of the requested drug to treat the provided diagnosis is an off-label use. 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 a Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Asacol HD 800 milligram tablets prescribed to treat ulcerative rectosigmoiditis without complications and ulcerative colitis, unspecified. 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 being 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.