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

At issue is Dexilant 60 milligram delayed release capsule tablet prescribed for nodularity of gastric antrum. 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 diagnosis reported is nodularity of gastric antrum and medical records do not support another diagnosis. However, 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 Dexilant.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epiceram Emulsion prescribed for skin irritation. The Part D plan denied the request. We received the case to perform 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. Epiceram is a topical barrier repair cream that is a Food and Drug Administration approved prescription medical device. Since this is considered a device, it is not eligible for Part D benefits. It may be covered under Part B benefits.  We have determined that the plan is not required to cover Epiceram Emulsion.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bystolic 20 milligram tablets 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.Bystolic is a brand drug on Tier 3 of the plans formulary. There are no other drugs of the same type on the lower cost sharing tiers. 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 Lumigan 0.01% eye drops 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.Lumigan is a brand drug on Tier 3 of the plans formulary. There are no other drugs of the same type on the lower cost sharing tiers. 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 Xtandi 80 milligram tablets prescribed for prostate cancer, high grade. 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 the drug at issue for the enrollees noted condition. The enrollee does not have castrate resistant disease and there is no evidence of metastatic disease. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There were no Medicare accepted journal articles submitted to support the use of the requested drug 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 a request for coverage of Testosterone 1 % (12.5 milligram per 1.25 gram) transdermal gel pump prescribed for the treatment of primary hypogonadism. 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 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 plan has prior authorization requirements that must be met before coverage of this medication will be approved. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Forteo 250 microgram/milliliter injection prescribed for age-related osteoporosis with current pathological fracture. 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. We requested additional documentation from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee met the plans prior authorization coverage criteria. We received additional information and included it in the review.The submitted documentation 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 Xarelto 15 milligram tablets prescribed for atrial fibrillation. 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.Xarelto is a brand drug on Tier 3 of the plans formulary. There are no other drugs of the same type on the lower cost sharing tiers. 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 a tiering exception request for Eliquis 5 milligram tablets prescribed for anticoagulation therapy due to protein C deficiency with personal history of recurrent deep vein thrombosis and pulmonary embolism. 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. Eliquis is a brand drug on Tier 3 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 3 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathioprine 50 milligram tablets prescribed for antiphospholipid antibody syndrome. 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 the drug at issue for the enrollees noted condition. 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 Metformin Extended Release 1000 milligram tablet prescribed for type 2 diabetes mellitus with hyperglycemia. 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 drug is not on the plans formulary. We requested additional information from the prescriber but did not receive a response. 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 prescriber does not indicate why the other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Metformin Extended Release 1000 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira Pen Injector Kit 40 milligram/0.8 milliliter. 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. We requested additional information 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 Humira Pen Injector Kit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus 0.1% ointment prescribed to treat the enrollee with granuloma annulare. The Part D plan denied the appeal 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 the doctor prescribed Tacrolimus 0.1% ointment to treat granuloma annulare. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition.A physician reviewed the appeal and determined that the plan is not required to cover Tacrolimus 0.1% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Gralise 600 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 Gralise has been prescribed for the treatment of radicular back (lumbar) pain that radiates to the arms and legs. However, the Medicare approved compendia do not contain any citations to support 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. 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 Saxenda 18 milligram/3 milliliter injection solution prescribed for obesity. 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 determined that the plan is not required to cover Saxenda because it was prescribed for obesity. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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

At issue is a tiering exception request for Lidocaine 5% patches prescribed for the treatment of left shoulder pain. 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. Lidocaine 5% patch is a generic drug on Tier 4 of the plans formulary. During this review, a request was submitted to the prescriber to address the generic drugs of the same type on the lower tiers of the plans formulary as to whether the drugs have been tried and failed, or are contraindicated. However, the prescriber did not respond to the request. Therefore, the tiering exception criteria have not been met. 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 4 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24-26 milligram tablets prescribed to treat the enrollees condition. 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 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.Entresto 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 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-Prilocaine 2.5%-2.5% cream prescribed as a topical anesthetic for dialysis access. 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 drug at issue is related to the enrollees end stage renal disease. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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

At issue is Symproic 0.2 milligram tablet prescribed for opioid induced constipation. 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. 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 prescriber indicates Lactulose oral solution and Relistor tablet have been or would likely be ineffective but does not indicate why all the other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Symproic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vascepa 1 gram capsules. 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 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.Vascepa 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 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 Dupixent Pen 300 milligram/2 milliliter prescribed for severe persistent asthma. 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. 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 prescriber does not indicate why all the other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rinvoq 15 milligram extended release tablets prescribed for rheumatoid arthritis without rheumatoid factor of multiple sites. 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.This drug is included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.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 a request for coverage of Vabomere 2 gram vials for intravenous infusion. 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 Vabomere has been prescribed for the treatment of an intra-abdominal abscess with multidrug resistant organism. However, the Medicare approved compendia do not contain any citations to support 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. 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 Xarelto 10 milligram tablets prescribed for deep vein thrombosis, prophylaxis. 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.Xarelto is a brand drug on Tier 3 of the plans formulary. There are no other drugs of the same type on the lower cost sharing tiers. 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 a prior authorization request for Xifaxan 550 milligram tablets prescribed for irritable bowel syndrome with diarrhea. 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 submitted documentation 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 Sildenafil 20 milligram tablet prescribed for pulmonary 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 records submitted at the reconsideration level. The prescriber indicates Sildenafil 20 milligram tablet is prescribed to treat WHO Group II pulmonary arterial hypertension. 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 Sildenafil. 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: Unfavorable

At issue is Dupixent Prefilled Syringe 300 milligram/2 milliliter prescribed for dermatitis, unspecified. 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 Dupixent Prefilled Syringe 300 milligram/2 milliliter to treat dermatitis, unspecified. However, 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 Dupixent.