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

At issue is Triazolam 0.25 milligram tablet prescribed for an unknown condition. The Part D plan denied the request because prior authorization requirements were not met.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. A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  Without a diagnosis it cannot be established that Triazolam is being prescribed for a medically accepted indication. As such, Triazolam 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 the appeal and determined that the plan is not required to cover Triazolam.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Clobazam 10 milligram tablet prescribed for localization-related focal epilepsy with simple partial seizures. 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 regulations and Medicare approved compendia.At reconsideration Clobazam 10 milligram tablet was prescribed for localization-related focal epilepsy with simple partial seizures.  A citation in Micromedex, a Medicare approved compendium, supports the use of the requested drug for the condition indicated:  Clobazam is adjunctive treatment of refractory focal seizures (partial seizure and localization-related seizure) in children, young adults, and adults if first-line treatment is ineffective or not tolerated . Therefore, it is considered a medically accepted indication.The documentation does not satisfy the plans coverage criteria. The plans coverage criteria state that you need to have an FDA approved indication.  Therefore, an exception to the plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Trulance 3 milligram tablets prescribed for chronic constipation. 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. Trulance is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives that are included in the plan to treat the enrollees condition, 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 request for coverage of Ambien 10 milligram tablets prescribed for an unknown condition. 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. Brand-name Ambien is not included in the plans formulary. The documentation does not include any medical records from the prescriber. A request was submitted to the prescriber to provide a diagnosis and supporting medical records and to address the alternative medications included in the plans formulary to treat the enrollees condition. A reply from the prescriber was not received. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested 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 a request for coverage of Tramadol Hydrochloride ER 300 milligram 24-hour extended release tablets prescribed for chronic pain due to trauma. 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. Tramadol Hydrochloride ER is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives that are included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. During this review, a request was submitted to the prescriber to address the alternative medications included in the plans formulary and to provide supporting medical records. The prescriber did not respond to the request. 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 Cosentyx 300 milligram-2 pens prescribed 30 per 90 days for plaque psoriasis. The Part D plan approved a recurring 30-day supply (8 pens/28 days) and denied the remaining 60-day supply.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 Cosentyx was prescribed to treat plaque psoriasis. Cosentyx is a brand drug in Tier 5 of the plan formulary. A long-term (up to a 90-day) supply for drugs in Tier 5 is not available. Therefore, the remaining 60-day supply cannot be considered.A physician reviewed your appeal and determined that the plan is not required to cover the remaining 60-day supply of Cosentyx, 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 a formulary exception request for Xywav 0.5 gram/milliliter solution prescribed for narcolepsy. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked your prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. We received the documentation and included it in our review.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Xywav.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone-Acetaminophen 10/325 milligram tablet prescribed every 8 hours for 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. The documentation shows Hydrocodone-Acetaminophen is prescribed to treat chronic low back pain. The prescriber indicates the pain is managed with long term narcotics at stable doses. However, there is no documentation the prescriber acknowledged the benefits outweighs the potential risks for this drug which has safety concerns; it can cause increased harm for patients 65 and older when taken with other medications acting on the central nervous system.  A physician reviewed your appeal and determined that the plan is not required to cover Hydrocodone-Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Viberzi 75 milligram tablets prescribed for irritable bowel syndrome with diarrhea. 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. Viberzi is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. During this review, a request was submitted to the prescriber to address the alternative medications included in the plans formulary and to provide supporting medical records. The prescriber did not respond to the request. 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 Methylphenidate Hydrochloride 18 milligram extended release 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.This drug is 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 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 Edarbyclor 40-25 milligram tablet prescribed for hypertension. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read 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 medication is not on your plan's list of medications. The prescriber has not given a clear and valid medical reason why all medications required by the plan, on that list, did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. Therefore, an exception to the plans formulary coverage criteria is not supported. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.A physician reviewed your appeal and determined that the plan is not required to cover Edarbyclor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lotemax 0.5% Eye Ointment to treat eczematous dermatitis of right upper eyelid. 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 Medicare approved compendia do not support the use of this drug for your conditions. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cosentyx 150 milligram/milliliter pen injector prescribed for hidradenitis suppurativa. 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 Cosentyx for hidradenitis suppurativa. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sensipar 30 milligram tablet prescribed daily for secondary hyperparathyroidism associated with end stage renal disease currently on dialysis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. Drugs which are eligible for Part B coverage are excluded from Part D coverage. We determined that the plan is not required to cover the Sensipar. 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: Favorable

At issue is Procrit 10,000 units per milliliter prescribed weekly for anemia associated with chronic kidney disease in patient not on dialysis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level.The medical records show the doctor prescribed Procrit to treat the enrollees anemia associated with chronic kidney disease in patient not on dialysis. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollees hemoglobin on July 16, 2021, was 7.3 grams per deciliter and Procrit is required to avoid blood transfusions. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Zaleplon 10 milligram capsules prescribed for insomnia. 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. Zaleplon is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. During this review, a request was submitted to the prescriber to address the alternative medications included in the plans formulary and to provide supporting medical records. The prescriber did not respond to the request. 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 Vyzulta 0.024% solution prescribed for open angle glaucoma. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber indicates they prescribed Vyzulta solution to treat glaucoma. The documents show the enrollee is allergic to Alphagan, Brimonidine, and Latanoprost. However, Vyzulta solution is not on the plans formulary. 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 Vyzulta solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fasenra 30-milligrams/milliliter Pen Solution Auto-Injector to treat mild asthma. 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 documentation does not satisfy the plans coverage criteria. 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 Buprenorphine Hydrochloride 2-milligram sublingual tablet to treat chronic pain 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 Medicare approved compendia do not support the use of this drug for your 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 is Nulojix 250 milligram solution prescribed for a post lung transplant enrollee. 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 Nulojix is prescribed for the enrollee due to post lung transplant status. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Nulojix.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Shingrix vaccine prescribed for shingles vaccination. The Part D plan denied the enrollee's 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 received the vaccination at a physicians office. The plan submitted documentation that shows coverage was provided for the Shingrix vaccination. According to your plans Evidence of Coverage, your copay amount is $100. The plan calculates reimbursement based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network provider charged you. We determined that the plan is not required to provide additional reimbursement for the Shingrix vaccine. The plan provided coverage and reimbursement in accordance with your plans out-of-network rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24-26 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.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 Colesevelam 625 milligram tablet prescribed for Crohns disease, short bowel syndrome and chronic diarrhea. 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 documentation shows Colesevelam was prescribed for Crohns disease, short bowel syndrome and chronic diarrhea. However, the Medicare approved compendia do not support the use of this drug for the enrollees conditions. A physician reviewed your appeal and determined that the plan is not required to cover Colesevelam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Botox 200 units reconstituted solution for injection prescribed for chronic migraines. 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. Botox is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale as to why all the formulary alternatives that are included in the plan to treat the enrollees condition 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.