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

At issue is Tagresso 80 milligram tablet prescribed for metastatic non-small-cell lung cancer. 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 Tagresso was prescribed for an enrollee with stage four metastatic non-small-cell lung cancer status post an extensive resection. Molecular profiling showed rare epidermal growth factor receptor mutation PG719X. The enrollee could not tolerate Afatinib and the dose was reduced and Tagrisso was requested as the prescriber felt this could be tolerated better. Per the Food and Drug Administration and Medicare approved compendia, Tagrisso is indicated for people with epidermal growth factor receptor exon 19, exon 21, and T790M mutation in metastatic lung cancer. The rare mutation that the enrollee has is not mentioned in compendia. However, the prescriber submitted an article from a Medicare approved journal called Tagrisso in Patients with Non-Small-Cell Lung Cancer Harboring Uncommon Epidermal Growth Factor Receptor mutations: A multicenter Open Label Phase 2 trial and includes the particular mutation that the enrollee has. One of the exclusions was if the patient had been on previous epidermal growth factor receptor tyrosine kinase inhibitors and the enrollee had but only briefly as the enrollee could not tolerate it. The study shows there was favorable activity of Tagrisso in rare epidermal growth factor receptor mutated lung cancers. Therefore, because the article is directly applicable to the enrollee and is from an approved journal, an exception can be made to the prior authorization criteria. A physician reviewed your appeal and determined that the plan is required to cover Tagresso.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Saxenda 18 microgram/3 milliliter 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.The record shows you were prescribed Saxenda for the treatment of weight gain. We determined the plan is not required to cover Saxenda because it is excluded from coverage under Part D. 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 Amphotericin D for Solution 50-milligram Solution to treat other specified respiratory disorder, lung transplant status, and pulmonary candidiasis prophylaxis. 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 diagnoses are off-label uses. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the 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 Risperidone 0.25 milligram tablets prescribed for burning mouth syndrome and trigeminal neuralgia. 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 Risperidone for burning mouth syndrome and trigeminal neuralgia. 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 Oxycodone-Acetaminophen 5-325 milligram tablet prescribed for 50 tablets per 12 days for chronic back pain. The Part D plan denied the request for a quantity exception of 50 tablets per 12 days.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 indicates they prescribed Oxycodone-Acetaminophen as the enrollee has been on the medication since 2010 and non-steroid anti-inflammatory drugs have become ineffective. However, the prescriber did not attest that the enrollees history of controlled substance prescriptions had been checked using the state prescription drug monitoring program and the risks and realistic benefits of opioid therapy have been discussed with the patient according to the prescriber.  A physician reviewed your appeal and determined that the plan is not required to cover 50 tablets per 12 days of Oxycodone-Acetaminophen 5-325 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ofev 150 milligram capsule prescribed twice daily for idiopathic pulmonary fibrosis and interstitial lung 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 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 doctor prescribed Ofev to treat the enrollees idiopathic pulmonary fibrosis and interstitial lung disease. The 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.The physician reviewer determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested reimbursement for the Shingrix 50 microgram/0.5 milliliter injection prescribed for shingles prophylaxis. The Part D plan denied the request.We requested 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 proof of partial payment for the vaccine and its administration fee has been provided. However, the plan provided information indicating the National Drug Code for the Shingrix vaccine was not included on the claim form. Medicare rules state that drug claims must include a valid National Drug Code that is listed with the Food and Drug Administration. The record includes a National Drug Code for the Shingrix vaccine. However, the National Drug Code 58160-0819-12 is not listed with the Food and Drug Administration as a valid code for the vaccine. Therefore, we determined that the plan is not required to reimburse the enrollee for the Shingrix vaccine and administration fee at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 5 milligram 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 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. Farxiga is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Piqray 300 milligram tablet prescribed daily for metastatic hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2) negative breast cancer. 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 doctor prescribed Piqray to treat the enrollees breast cancer. However, the Medicare approved compendia do not support using Piqray with Tamoxifen. Therefore, the requested drug is not being prescribed for a medically accepted indication.A physician reviewed the appeal and determined that the plan is not required to cover Piqray.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100/62.5 microgram inhaler. 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 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. Trelegy Ellipta brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Metformin Hydrochloride  1000 milligram tablet  prescribed for unknown diagnosis. 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 that you are enrolled in a primary insurance plan that is not Medicare Part D. The pharmacy should bill the prescription for Metformin Hydrochloride to the primary plan before billing Medicare Part D plan. The Medicare Part D Plan is not required to process the claim until after your primary insurance has processed it. There was no Explanation of Benefits from your primary insurance provided to indicate that the primary insurance processed the claim for this drug.We have determined that the plan is not required to allow coverage as secondary payer. You may resubmit your claim to your Part D plan once your primary insurance has processed it.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Telmisartan 80 milligram tablet  prescribed for unknown diagnosis. 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 that you are enrolled in a primary insurance plan that is not Medicare Part D. The pharmacy should bill the prescription for Telmisartan to the primary plan before billing Medicare Part D plan. The Medicare Part D Plan is not required to process the claim until after your primary insurance has processed it. There was no Explanation of Benefits from your primary insurance provided to indicate that the primary insurance processed the claim for this drug.We have determined that the plan is not required to allow coverage as secondary payer. You may resubmit your claim to your Part D plan once your primary insurance has processed it.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methocarbamol 750 milligram tablet prescribed three times per day for trigeminal neuralgia. 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 doctor prescribed Methocarbamol 750 milligram tablet to treat the enrollees trigeminal neuralgia. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Methocarbamol 750 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symproic 0.2 milligram tablet prescribed once daily for chronic 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 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. A physician reviewed the appeal and determined that the plan is not required to cover Symproic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brinzolamide 1% eye drops prescribed for low tension glaucoma of both eyes, severe stage. 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 the 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 Brinzolamide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 50 milligram tablet prescribed 1 every night for trigeminal neuralgia, insomnia, and headaches. 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 prescriber has requested Ubrelvy 50 milligram tablets prescribed 1 tablet every night. The records support the enrollee has underlying migraines and severe recurrent headaches. However, the Medicare approved compendia do not support the use of this drug for your condition. It is approved for acute migraines and is not indicated for the prevention of migraines. A physician reviewed your appeal and determined that the plan is not required to cover Ubrelvy.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xolair 150 milligram/milliliter syringe prescribed for idiopathic anaphylaxis. The case was auto-forwarded by the plan.  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 Xolair was prescribed to treat idiopathic anaphylaxis. However, 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 Xolair.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hizentra solution 10 gram/50 milliliter to be given subcutaneous via pump in the home to treat common variable immunodeficiency, unspecified. The Part D plan denied the request for Part D coverage but approved the request under Part B 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 records indicate the drug is requested to treat common variable immunodeficiency and it will be given in the home. This drug is not eligible for coverage under Part D drug benefits. However, this drug may be covered under Medicare Part B benefits. We determined that the plan is not required to cover Hizentra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cialis 20 milligram tablet prescribed daily for benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. 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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. We initially did not receive the documentation. However, the documentation has been submitted and we have included it in our review.The medical records show the physician prescribed Cialis 20 milligram tablet to treat the enrollees benign prostatic hyperplasia with lower urinary tract symptoms. The Medicare approved compendia and the FDA label do not reference the 20 mg dosage as a medically accepted dosage for the treatment of BPH. Each reference indicates the 5 mg dosage used once daily at the same time every day. Therefore the requested dosage is not a medically accepted dosage for this indication.A physician reviewed the appeal and determined that the plan is not required to cover Cialis 20 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Umbrelvy 100 milligram tablet prescribed for chronic migraine without aura, intractable, without status migrainosus. 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 show Umbrelvy was prescribed to treat chronic migraine aura, intractable, without status migrainosus. However, 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 Umbrelvy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mavyret 100 milligram-40 milligram tablet prescribed for hepatitis C virus in an enrollee also with a diagnosis of cirrhosis. 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 medical records support the enrollee has hepatitis C genotype 3 and a diagnosis of cirrhosis. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Mavyret.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sofosbuvir/Velpatasvir 400 milligram/100 milligram tablets prescribed for chronic hepatitis C infection, genotype 2, treatment naive without cirrhosis. 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. The prescriber indicated on appeal that the formulary alternative, Epclusa, was the drug ordered. However, the plan has not performed a coverage determination for Epclusa, the documentation supports the generic medication Sofosbuvir/Velpatasvir is the drug at issue; therefore, we cannot address Epclusa.  A physician reviewed your appeal and determined that the plan is not required to cover Sofosbuvir/Velpatasvir.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Lorazepam 0.5 milligram tablets prescribed for insomnia. 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 documentation on hand includes a physician supporting statement. The supporting statement 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: Favorable

You asked for reimbursement for Entresto 24-26 milligram tablet prescribed for congestive heart failure. 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 information provided supports the diagnosis of congestive heart failure and a receipt is included that shows the amount requested of $640.31 was paid specifically for this drug. The requirements have been met for reimbursement.A physician reviewed your appeal and determined that the plan is required to reimburse the amount of Entresto.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Otezla 30 milligram tablet prescribed for psoriasis vulgaris. 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 records submitted at the reconsideration level. The documentation shows Otezla was prescribed to treat psoriasis vulgaris. The 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 Otezla. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.