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

You requested Hizentra 1 gram/5 milliliter syringe prescribed for common variable immunodeficiency. 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 Hizentra is being administered through an external infusion pump in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Hizentra. Please consider submitting your request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis 0.05% ophthalmic emulsion to treat dry eye syndrome. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read all documentation submitted. This includes the any information submitted at the reconsideration level.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the alternative 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

You requested Omega-3-acid ethyl esters 1-gram capsules prescribed as directed for hypertriglyceridemia. 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 medical records show the doctor prescribed Omega-3-acid ethyl esters for hypertriglyceridemia. The documentation shows the enrollees pre-treatment triglyceride level was 157 in 2013. The level was not greater than or equal to 500 milligrams per deciliter as required. 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 Omega-3-acid ethyl esters.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Fycompa 8 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.Fycompa is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 15 milligram tablet to treat hypothyroidism.   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.Non-FDA approved drugs are excluded from Medicare Part D coverage.  Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle Libre 14 Day Sensor prescribed for monitoring your blood glucose levels. The Part D plan denied the appeal because this item is not considered a medical supply directly associated with the delivery of insulin for purposes of coverage under Part D. We received an auto forwarded 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. Your medical record shows that you are a person with diabetes. Glucose monitoring supplies are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Medicare Part D. As such, the Freestyle Libre 14 Day Sensor are excluded from Part D coverage by Medicare law.We have determined that your plan is not required to cover Freestyle Libre 14 Day Sensor. Medicare Part B/Durable Medical Equipment is responsible.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a Freestyle Libre 2 Reader device prescribed as directed. 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 you requested coverage for a Freestyle Libre 2 Reader device. However, this product may be eligible for coverage under Medicare Part B. Medicare rules state drugs and medical supplies not directly associated with the injection of insulin are not covered under Part D. 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.We determined that the plan is not required to cover the Freestyle Libre 2 Reader device.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Combivent Respimat 20-100 micrograms prescribed to treat chronic obstructive pulmonary disease. The Part D plan denied your request for a 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. The drug requested is not on the plans formulary. There are no medical records supporting that all alternative drugs on the plans formulary, to treat the same condition, have been tried. A physician reviewed your appeal and determined that the plan is not required to cover Combivent Respimat.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 1 milligram pen injector to treat type 2 diabetes mellitus. The plan did not make a decision within the required timeframe. The case was auto-forwarded by the plan.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 no indicated why all alternatives required by the plan would likely not be as effective as the requested drug. Therefore, an exception to the plans coverage criteria is not met. Our physician reviewer's opinion is that step therapy exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Depo-testosterone 200 milligrams. 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 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 formulary alternatives. We received the documentation and included it in our review.The prescribers statement shows you were prescribed Depo-testosterone to treat your hypogonadism, male. However, there were no medical records submitted to confirm the diagnosis listed. Therefore, based upon the current record, it could not be determined whether the requested drug was being prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a quantity limit exception for Forteo 620 microgram/2.48 milliliter pen injector prescribed for primary osteoporosis in a male. 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 documentation indicates your doctor prescribed Forteo for primary osteoporosis in a male. The drug at issue was approved as a specialty drug, which is only approved for a 30-day supply. An exception to the quantity limit criteria was not met. Of note, your doctor has indicated a change to the requested quantity for a recurring 30-day supply.Therefore, the plan is not required to cover Forteo for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathioprine 50 milligram tablet to treat idiopathic follicular bronchiolitis.  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 your appeal and determined that the plan is not required to cover Azathioprine 50 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Lidocaine 5 percent patches prescribed daily for pain in left hip. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration 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 record shows you were prescribed Lidocaine patches for pain in left hip. We asked your doctor to send us a supporting statement to show why Lidocaine is medically necessary for you. No additional documentation was received.In review of the Medicare approved compendium, pain in left hip is not a medically accepted indication for Lidocaine patches as prescribed. The only indication is pain associated with post herpetic neuralgia and your records do not support this condition. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Lidocaine 5 percent patches at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig 70 milligram/milliliter auto-injector for migraine prevention. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Aimovig to treat your migraines. The Medicare approved compendia do support the use of this drug for your condition.The plan requires an intolerance or contraindication to two of the following migraine prevention drugs:  Topiramate, Divalproex, Valproic Acid, Propranolol, Metoprolol, Amitriptyline, and Venlafaxine before they will cover the requested drug 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 Aimovig.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Entresto 24-milligrams-26-milligrams to treat the congestive heart failure. 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.Entresto 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 Jardiance 25 milligram oral tablet prescribed for type II diabetes mellitus. The Part D plan denied your request for a tiering exception. 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.Jardiance is a brand name drug on Tier 3 of the plans formulary. There are no brand name drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception. There are no lower tiered brand drugs of the same type to treat your condition.A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Proctofoam Hydrocloride 1% Foam prescribed for hemorroids. The Part D plan denied your request for a 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. The drug requested is not on the plans formulary. There are no medical records supporting that all alternative drugs on the plans formulary, to treat the same condition, have been tried. A physician reviewed your appeal and determined that the plan is not required to cover Proctofoam Hydrocloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Breztri Aerosphere aerosol inhaler prescribed for chronic obstructive pulmonary disease. The Part D plan denied your request because the documentation did not support an off-formulary exception. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. 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 Eysuvis 0.25% ophthalmic suspension to treat the diagnosis of dry eye syndrome. 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.Dupixent is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain 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.A physician reviewed your appeal and determined that the plan is not required to cover Eysuvis 0.25% ophthalmic suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Plegridy 125 micrograms/0.5 milliliters prefilled syringe for injection prescribed as directed for multiple sclerosis. 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 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 a tiering exception request for Amphetamine-Dextroamphetamine 20 milligram tablet 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.Amphetamine-Dextroamphetamine is a generic drug on Tier 3 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 a tiering exception request for Rytary 48.75 milligram-195 milligram ER capsules 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.Rytary is a non-formulary drug. Non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron HCL 4 milligram tablets prescribed as needed for nausea and vomiting due to chronic migraines. 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 also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Ondansetron 4 milligrams as needed to treat your nausea and vomiting due to chronic migraines. 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 Ondansetron HCL tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine 25 milligram suppository to treat nausea with vomiting. 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 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

You requested coverage for Dupixent 300 milligrams per 2 milliliter solution prefilled syringe prescribed daily for severe bullous pemphigoid. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration 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 record shows you were prescribed Dupixent for severe bullous pemphigoid. In review of the Medicare approved compendia, severe bullous pemphigoid is not a medically accepted indication for Dupixent. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Dupixent at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vancomycin 125 milligram capsules prescribed twice daily for Clostridium difficile associated diarrhea. 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 medical records show the doctor prescribed Vancomycin to treat Clostridium difficile associated diarrhea. The prescriber statement indicates 40 capsules of Vancomycin per 30 days does not manage the enrollees diarrhea. The available medical records do not support this statement. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover the requested quantity of 60 capsules of Vancomycin 125 milligrams per 30 days.A physician reviewed your appeal and determined that the plan is not required to cover the Vancomycin, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Envarsus XR 4 milligram tablets prescribed daily following a kidney transplant. 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. We also researched Medicare systems and reviewed the enrollment data available. Your records show your doctor prescribed Envarsus XR to prevent rejection following a kidney transplant. The Medicare approved compendia support the use of this drug for your condition. Based on the information provided, the drug is eligible for Part B coverage. Therefore, the drug is not eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is not required to cover Envarsus XR.