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

You requested a tiering exception for Myrbetriq ER 50 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request. 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. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Myrbetriq ER is a brand name Tier 4 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Afatinib 20 milligram tablet prescribed daily for metastatic prostate cancer with epidermal growth factor receptor amplification. 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 Afatinib 20 milligram tablet to treat the enrollees metastatic prostate cancer with epidermal growth factor receptor amplification. However, the 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 Afatinib 20 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Symbicort 160-4.5 microgram metered aerosol prescribed for an enrollee with chronic obstructive pulmonary disease and asthma exacerbation. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.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 Symbicort 160-4.5 microgram metered aerosol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Teriparatide 600 microgram/2.4 milliliter injection prescribed daily for osteoporosis. 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. Specifically, we asked for records to show why all alternative medications on the plan's formulary could not be used to treat your condition. We received the documentation and included it in our review.The records submitted show your doctor prescribed generic Teriparatide to treat your condition. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Other drugs on the formulary may have prior authorization requirements that must be met. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover Teriparatide because your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligram tablet prescribed twice daily for psoriatic arthritis. The Part D plan denied your request because the documentation did not support an off-formulary 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.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, medical records have not been submitted to 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 Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mitomycin 0.02% eyedrops. 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.We determined that the plan is not required to cover Mitomycin eyedrops. Drugs compounded from bulk powders are not Food and Drug Administration approved and are therefore not covered under Part D. The plan is not required to cover the Mitomycin at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 150 microgram tablets prescribed daily for hypothyroidism. 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. We also researched Medicare systems and reviewed the enrollment data available. Synthroid 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 Bupropion Hydrochloride 100 milligram tablet prescribed for depression. 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. Bupropion Hydrochloride is a generic drug on Tier 3 of the plans formulary. The prescriber did not address why the drugs available on the lower tiers of the plans formulary would not work for the enrollees 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

You requested First-Lansoprazole 3 milligram/milliliter suspension. 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 record shows your physician prescribed First-Lansoprazole as you have tongue cancer and cannot swallow medication. The drug at issue is not Food and Drug Administration approved. Therefore, the drug cannot be considered a Part D benefit.We determined that the plan is not required to cover the First-Lansoprazole.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chlorthalidone 25 milligram tablets prescribed for the enrollees condition. 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.Chlorthalidone is a generic drug on Tier 2 of the plans formulary. Your doctor submitted a supporting statement. The statement did not address why two of the alternative lower-tier medication on the plans formulary would not work for you. Two of the generic drugs on lower tiers have not been tried. 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 Repatha Sureclick 140 milligram/milliliter autoinjector prescribed every 14 days for familial hypercholesterolemia and hyperlipidemia. 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 biologic not on the plans formulary, alternative formulary drugs and biologics must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other biologics and drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick 140 milligram/milliliter autoinjector.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Guanfacine Extended-Release 1 milligram tablet prescribed to take 1.5 tablets, daily for hypertension. A quantity of 135 tablets for 90 days. 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 Guanfacine Extended-Release to treat your hypertension. However, the Medicare approved compendia do not support the use of this specific drug form for your condition due to not being immediate-release. A physician reviewed your appeal and determined that the plan is not required to cover Guanfacine Extended-Release.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcipotriene 0.005 percent cream prescribed as directed for psoriasis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Calcipotriene to treat your psoriasis. 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 Calcipotriene because the Plans prior authorization requirements were not met. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Favorable

You requested Sprycel 100 milligram tablet prescribed daily for chronic myeloid leukemia. 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 medical records show your doctor prescribed Sprycel to treat your chronic myeloid leukemia which was confirmed with a bone marrow biopsy. The Medicare approved compendia supports the use of this drug for your condition.A physician reviewed your appeal and determined that the plan is required to cover Sprycel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epclusa 400/100 milligram tablet prescribed as directed for hepatitis C. 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 and provide a diagnosis. We also asked for medical records or other documentation to show why you need this medication. Specifically, we asked your provider to address the plans prior authorization criteria. We did not receive the documentation requested. No medical records were provided by the prescriber. 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.A physician reviewed your appeal and determined that the plan is not required to cover the Epclusa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Timoptic 0.5% Ocudose drops prescribed for primary open angle glaucoma. 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 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. A physician reviewed your appeal and determined that the plan is not required to cover Timoptic Ocudose drops.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Northera 200 milligram capsules. 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 Northera has been prescribed for orthostatic hypotension. The Medicare approved compendia indicate that a medically acceptable use of Northera is for the treatment of neurogenic symptomatic orthostatic hypotension in patients with primary autonomic failure, dopamine-beta-hydroxylase deficiency, or nondiabetic autonomic neuropathy. However, the medical records do not indicate that the enrollee has primary autonomic failure, dopamine-beta-hydroxylase deficiency, or nondiabetic autonomic neuropathy. 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 Northera.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is OxyContin ER 30 milligram tablet prescribed for chronic low back pain and osteoarthritis. The Part D plan denied your request because the documentation did not support an off-formulary 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. 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 prescribers statement and medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover OxyContin ER.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Venclexta 100 milligram tablet prescribed for chronic myelomonocytic leukemia. 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.The medical records show you prescribed Venclexta 100 milligram tablet to treat the enrollees chronic myelomonocytic leukemia. The medical records also indicate that the enrollee has exhausted all National Comprehensive Cancer Network recommended treatment of the disease. The records include an article from Blood, a Medicare approved journal, titled 'Activity of Venetoclax Based Therapy in Myelodysplastic Syndromes. In this article, patients had been on previous treatments, including chronic myelomonocytic leukemia patients. The study treated chronic myelomonocytic leukemia patients with Venclexta in combination with Azacitidine.' In this retrospective study, there was a clinical benefit for patients. The medical records submitted make no mention of combining Venclexta and Azacitidine with a steroid. The provider is treating in accordance with the study provided. Therefore, this treatment regimen is acceptable. An oncologist reviewed your appeal and determined that the plan is required to cover Venclexta 100 milligram tablet with an exception to the plans prior authorization requirements.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Auryxia 210 milligram tablets to treat iron deficiency anemia in chronic kidney disease not on dialysis. 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.Drugs prescribed for use as vitamins and minerals are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ensure plus liquid prescribed as directed for severe anorexia. 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 also researched Medicare systems and reviewed the enrollment data available. We determined that the plan is not required to cover MEDICATION because it is an over-the-counter drug product. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Rhopressa 0.02 percent solution prescribed for open angle glaucoma. The Part D plan denied your request. 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. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Rhopressa is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pregabalin 100 milligram capsules prescribed for muscle spasms related to an acute, painful musculoskeletal condition. 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. The submitted documentation indicates your doctor prescribed Pregabalin for muscle spasms related to an acute, painful musculoskeletal condition. The Medicare approved compendia do not support the use of this drug for your condition. As 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

You requested Nexplanon 68 milligram implant prescribed as directed for abnormal uterine bleeding. 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. Your medical records show your doctor prescribed Nexplanon to treat your abnormal uterine bleeding. However, the Medicare approved compendia do not support the use of this drug for your conditions. 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 Nexplanon.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent patches prescribed as directed for neuropathy, cervical dysplasia, spondylosis of lumbar joint, and neck pain. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any 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. We requested additional information from the prescriber and did not receive a response. 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 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 Lidocaine 5 percent patches.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sodium Chloride 0.9% solution. 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.There is insufficient evidence to support the drug requested. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  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 Sodium Chloride.