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

You requested Gleostine 40 milligram capsules prescribed as directed for glioblastoma. 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.According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the March 2021 published list, the manufacturer of Gleostine has not signed the agreement and does participate in the Medicare Gap Discount Program. We reviewed your appeal and determined that the plan is not required to cover the Gleostine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ocrevus 300 milligram/10 milliliter vial per 30 days prescribed for multiple sclerosis. The Part D plan denied your request.We received a 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 Ocrevus is being administered through an external infusion pump in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Ocrevus. Please consider submitting your request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Tecfidera 240 milligram delayed release capsules for the treatment of multiple sclerosis. 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. Tecfidera is not included in the plans formulary. The prescriber has not sufficiently addressed why all alternative medications included in the plans formulary to treat the noted 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 Xarelto 15 milligram tablets prescribed to treat the diagnosis of atrial fibrillation. 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.The use of the requested drug to treat the provided diagnoses 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 your conditions. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Xarelto 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

You requested Lorazepam 1 milligram tablets prescribed twice daily for sleep apnea. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation indicates your doctor originally prescribed Lorazepam for sleep apnea. Your doctor submitted a supporting statement to indicate the diagnosis should be generalized anxiety disorder; however, there were no medical records submitted to corroborate the change in diagnosis. The Medicare approved compendia do not support the use of the drug for your condition. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Durezol Emulsion 0.05% prescribed to treat paraneoplastic retinopathy and autoimmune retinopathy. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. We also researched Medicare regulations and Medicare approved compendia. The physician submitted additional diagnosis codes but no supporting medical records. 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 Durezol Emulsion.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nuedexta 20/10 milligram tablets to treat pseudobulbar affect related to post traumatic stress disorder. The Part D plan denied the request as not a medically accepted indication. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The FDA drug label for Nuedexta states, NUEDEXTA is a combination product containing dextromethorphan hydrobromide (an uncompetitive NMDA receptor antagonist and sigma-1 agonist) and quinidine sulfate (a CYP450 2D6 inhibitor) indicated for the treatment of pseudobulbar affect (PBA). No qualifications are made as to the underlying disease process. Therefore the drug is being used for a medically accepted indication.The records from the plan, prior approvals, and the prescriber indicate that enrollee has been using this medication for some time. Prescriber, a psychiatry office, indicates that drug has been effective in controlling emotional outbursts. Prescriber statement of March 11, 2021, indicates this drug has been effective in controlling inappropriate laughing and crying episodes.The plans prior authorization criteria for reauthorization of this drug have been satisfied by the documentation provided. 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 Temazepam 7.5 milligrams capsules to treat insomnia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The prescriber has not indicated why all alternatives which are required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Plenvu powder packets prescribed as directed prior to an encounter for screening for malignant neoplasm of colon. 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 physician states the enrollee has tried and failed the use of some drugs for their condition. No medical records are provided. The records do not show why the enrollee cannot take other drugs on the plans formulary for their condition.A physician reviewed your appeal and determined that the plan is not required to cover the Plenvu powder packets.
Appeal type: Prescription Drug
Decision: Favorable

You requested Cresemba 186 milligram capsules prescribed for osteomyelitis caused by candida. 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. Your medical records show your doctor prescribed the requested drug to treat osteomyelitis due to candida glabrata. The Medicare approved compendium indicates the drug at issue is labelled an orphan drug to treat invasive candidiasis infections. Furthermore, your doctor indicated on a prior authorization form that you have familial short QT syndrome, which is a contraindication for the drug at issue. However, the medical records submitted and a comment on the prior authorization form indicate you had prolonged QT intervals and not short QT intervals. The plans prior authorization criteria have been met. A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Pushtronex 420 milligram/3.5 milliliter injection prescribed for atherosclerotic cardiovascular disease. 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. Your physician submitted a supporting statement. The supporting statement did not indicate adequately address that the formulary alternatives would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Repatha Pushtronex.
Appeal type: Prescription Drug
Decision: Favorable

You requested Duloxetine HCL DR 60 milligram capsules prescribed to treat a diagnosis of major depressive disorder. The Part D Plan allowed 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.The record shows the plan has granted your request for a tiering exception. The requested drug has been approved at Tier 1 under Medicare Part D from February 24, 2021, through December 31, 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Truxima 10 milligram/milliliter vial prescribed to treat rheumatoid arthritis.  The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The plan requires prior authorization criteria be met for this drug to be covered. There are no medical records submitted that support it has been 16 weeks or greater since the first dose of the previous Rituximab product. The prior authorization requirements were not met. A physician reviewed your appeal and determined that the plan is not required to cover Truxima.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 50 milligram tablets prescribed to treat the diagnosis of overactive bladder. 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.Myrbetriq 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 Nuedexta 20 milligram-10 milligram capsules prescribed for pseudobulbar affect. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of pseudobulbar affect. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Escitalopram oxalate 10 milligram tablets prescribed for unknown diagnosis. The Part D plan denied your request.We received a case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows you purchased the Excitalopram oxalate from a preferred pharmacy. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plans formulary shows the drug is covered as a Tier 1 drug. The documentation includes pharmacy receipts indicating you paid for the Excitalopram oxalate in full. We determined that the plan is required to reimburse you for their share of the cost.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tobramycin and Dexamethasone 0.3-0.1% ophthalmic solution prescribed for a right eye infection. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows your doctor prescribed one 5.0 milliliter bottle of Tobramycin and Dexamethasone 0.3-0.1% ophthalmic solution on January 28, 2020, for a left eye infection. The records also indicate that your doctor subsequently prescribed another bottle of the same medication on February 3, 2020, for a right eye infection. There is no indication that the first 5.0 milliliter bottle prescribed on January 28, 2020, was emptied by February 3, 2020. The refill for the second bottle of Tobramycin and Dexamethasone 0.3-0.1% was filled too soon. A physician reviewed your appeal and determined that the plan is not required to reimburse the Tobramycin and Dexamethasone 0.3-0.1% ophthalmic solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fetanyl 37.5 microgram patch. The Part D plan denied the request for reimbursement. 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. No medical records were provided by the prescriber. It could not be determined 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 your appeal and determined that the plan is not required to reimburse payment for the Fetanyl patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Famotidine 40 milligrams prescribed for gastroesophageal reflux disease. The Part D plan denied your request for a tiering exception because Famotidine is a generic Tier 2 drug and there are no lower tier alternatives for your condition. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Famotidine is a generic Tier 2 drug. There are no lower tier alternatives for your condition. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate motefil 500 milligrams. The Part D plan denied the request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber was asked to send in medical records to support the diagnosis listed and the date of the liver transplant. A response from the prescriber was not received. Therefore, based upon the current record, it could not be determined 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets prescribed as directed to treat the enrollees condition. 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.Eliquis is a brand drug on Tier 2 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

You requested a tiering exception for Butalbital-Acetaminophen-Caffeine 50 milligram-30 milligram-40 milligram capsules to treat tension-type 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.Butalbital-Acetaminophen-Caffeine is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. In addition, a tiering exception cannot be allowed for a non-formulary drug. Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Butalbital-Acetaminophen-Caffeine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 10 milligram oral tablet prescribed for diabetes. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Jardiance is a brand 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. There are no lower tiered brand drugs of the same type to treat your condition.A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 20 milligram tablets to treat erectile dysfunction. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tramadol HCL ER 100 milligram tablet, 180 tablets per 90 days, 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 plan limits the amount of Tramadol HCL ER provided to a 30 day supply. The plan approved coverage for Tramadol HCL ER 100 milligram tablet, 60 tablets for 30 days. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Corlanor 5 milligram tablets prescribed for congestive heart failure with mitral valve stenosis. 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 does not satisfy the plans coverage criteria. The prescriber has addressed the prior authorization criteria; however, the responses do not satisfy the all of the plans requirements for coverage of this medication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage. Also, since the medication is not eligible for coverage, a lower cost tiering exception will not be addressed.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temazepam 30 milligrams. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. No medical records were provided by the prescriber. It could not be determined 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 your appeal and determined that the plan is not required to cover the Temazepam because it was not prescribed for a medically accepted indication.