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

At issue is Dupixent 300 milligram/2 milliliter pen injector prescribed for atopic dermatitis. 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.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. 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. 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 Anoro Ellipta 62.5- 25 microgram inhaler prescribed for chronic obstructive pulmonary disease. 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 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 Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Opium Tincture 10 milligram/milliliter oral solution prescribed for diarrhea.  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.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

At issue is Nucala 100-milligrams/milliliter Solution Auto-Injector to treat eosinophilic asthma, mild persistent asthma without complication, and eosinophilia, unspecified type. 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.At reconsideration, the diagnosis of moderate persistent asthma with exacerbation is noted in the physician progress note dated June 15, 2021. However, 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 Briviact 50 milligram tablets prescribed for seizure disorder. 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 documentation submitted indicates the prescriber ordered Briviact for seizure disorder. The plan has prior authorization requirements for this drug that must be met before the plan will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Briviact. 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 Ztlido 1.8% patch prescribed for cervicalgia and shoulder pain. 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 documentation shows the prescriber ordered Ztlido 1.8% patch for cervicalgia and shoulder pain. 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 Ztlido.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Briviact 400 milligram tablets prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is included on Tier 4 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 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 Budesonide-Formoterol Fumarate Aerosol 80-4.5-milligrams/Actuation to treat an unknown condition. 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.We asked your prescriber to send us a prescriber statement, answers to off formulary coverage criteria, and medical records. However, we did not receive the documentation.No medical records were provided by the prescriber to support this diagnosis. Without medical records we could determine 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spiriva HandiHaler 18 microgram capsule  prescribed as directed for chronic obstructive pulmonary disease, 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. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you.  However, we did not receive the documentation.. 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 Spiriva HandiHaler.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Topamax 50 milligram tablets prescribed as directed for major depressive disorder. 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. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you.  However, we did not receive the documentation.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 Topamax.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Imipramine Hydrochloride 25 milligram tablet prescribed for overactive bladder. 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. The prescriber indicates Imipramine Hydrochloride is prescribed for overactive bladder. The medical records show that the enrollee has urinary incontinence especially when standing and urge incontinence. However, 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 in males. 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 Imipramine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of a Lidocaine 5%.  For initial determination a diagnosis of dorsalgia was given. 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. At redetermination a diagnosis of chronic back pain due to neuropathy was given. However, the Medicare approved compendia do not support the use of Lidocaine 5% patch for this condition.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We received the documentation and included it in our review.A prescribers statement was received that shows Lidocaine 5% patch was prescribed to treat post herpetic neuralgia. However, medical records were not submitted to support a medically accepted indication A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pomalyst 1 milligram capsules prescribed for multiple myeloma. 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 documentation shows the prescriber ordered Pomalyst for multiple myeloma in an enrollee that has not been previously treated with a proteasome inhibitor. However, the Medicare approved compendia do not support the use of this drug for your condition. There are no Medicare accepted journal articles to support the use of Pomalyst for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Pomalyst.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Durolane 60 milligram/3 milliliter prescribed for injection into the knee for bilateral primary osteoarthritis of the knee. 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 determined that the plan is not required to cover the Durolane 60 milligram/3 milliliter. Durolane 60 milligram/3 milliliter is a drug that is injected into the knee and is considered a medical device by the Food and Drug Administration. Therefore, the device is excluded from coverage under Medicare Part D. The Durolane may be covered under Medicare Part B. The decision does not address medical necessity of the device. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Emgality 120-milligrams/milliliter to treat trigeminal autonomic cephalagias and side-locked left sided headache. 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 a prescriber statement, to clarify the diagnosis and medical history, to answer the non-formulary exception coverage criteria, and to provide supporting medical records. We did not receive the information requested.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.  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.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Wegovy 0.5 milligram/0.5 milliliter solution auto-injector pen prescribed to treat obesity. 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 determined the plan is not required to cover Wegovy because it is excluded from coverage under Part D. The record shows the enrollee was prescribed Wegovy for the treatment of weight gain. Medicare rules state that drugs used for treatment of weight loss or weight gain are statutorily excluded from coverage under the Part D benefit. If you purchased drugs/products that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug/product. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Austedo 9 milligram tablets prescribed 6 tablets daily for Huntingtons disease. 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 Austedo was prescribed to treat Huntingtons disease. However, the Medicare approved compendia do not support the dosing of Austedo, 54 milligrams per day, for the enrollees condition.  The product label, available at drugs@fda.gov, states:  Maximum dose 48 mg/day for Chorea associated with Huntington's disease. A physician reviewed your appeal and determined that the plan is not required to cover Austedo, 54 milligrams per day.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Stelara 45mg/0.5ml solution for injection prescribed as directed for pityriasis rubra pilaris and rash. 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 Stelara to treat your pityriasis rubra pilaris and rash. 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 Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bystolic 10 milligram tablets prescribed to treat the enrollee's 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 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 Nexletol 180 milligram tablets prescribed for unspecified hyperlipidemia. 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.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 Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mesalamine 1.2 gram DR tablet. 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. Mesalamine 1.2 gram DR tablet is a generic drug on Tier 4 of the plans formulary. The doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for the enrollee. Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sodium Fluoride 1.1% dental cream prescribed for dental care. 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 plan denied the request for coverage of the requested drug to treat the provided diagnosis because the plan's Medicare Part D drug plan cannot cover drugs classified as being part of the Food and Drug Administration (FDA)'s Drug Efficacy Study Implementation (DESI) program. These drugs are considered to be Less than Effective (LTE) per FDA review.A physician reviewed your appeal and determined that the plan is not required to cover the Sodium Fluoride dental cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Guanfacine Hydrochloride 2 milligram tablets prescribed for autistic disorder, schizoaffective disorder, and attention deficit hyperactivity disorder in an adult enrollee. 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 documentation shows the prescriber ordered Guanfacine Hydrochloride for autistic disorder, schizoaffective disorder, and attention deficit hyperactivity disorder in an adult enrollee. 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 Guanfacine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested compounded drug Stanozolo micronized powder 1 milligram prescribed for the treatment of lipodermatosclerosis. 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 determined that the plan is not required to cover the Stanozolo micronized powder. According to Medicare rules, drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The Stanozolo micronized powder is considered a bulk powder and therefore, is excluded from coverage under the Part D benefit. The plan indicates that supplemental benefits for this drug are not offered. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colistemethate Sodium 150 milligram nebulizer solution prescribed for cystic fibrosis. 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 not Food and Drug Administration approved for nebulization. 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.