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

At issue a request for coverage of Farxiga 10 milligram tablets prescribed for type 2 diabetes mellitus with established coronary artery disease. 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.Farxiga 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. 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: Favorable

You requested Tacrolimus 0.1% ointment prescribed for unknown diagnosis. 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 purchased the Tacrolimus ointment from your pharmacy. Medicare rules state that if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The documentation provided includes a letter from the plan indicating the Tacrolimus ointment has been approved from April 7, 2021 through May 8, 2021. In this case, a receipt was provided showing you paid for the Tacrolimus ointment for the total amount charged. We determined that the plan is required to reimburse you the amount of total price paid, minus any applicable tiered copayment/coinsurance amount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is an off formulary exception for Tadalafil 5 milligram tablets as needed 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

You requested Clonazepam prescribed for an unknown diagnosis. 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 reprocessed claims for the Clonazepam and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram capsule prescribed for pain due to bilateral osteoarthritis of the hips. 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 Dronabinol to treat your pain due to bilateral osteoarthritis of the hips.  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 Dronabinol under your Part D benefit. However, Dronabinol was approved under your enhanced coverage benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Corlanor 5 milligram tablets prescribed to treat postural orthostatic tachycardia syndrome. 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 Corlanor 5 milligram tablets to treat postural orthostatic tachycardia syndrome. 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 Corlanor 5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ibrance 125 milligram capsule prescribed for unknown diagnosis.We received the 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 Ibrance from a pharmacy for an amount that is less than or equal to the required copay/coinsurance amount. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for a tier 5 drug in the catastrophic coverage phase. You are responsible for your share of the remaining copay/coinsurance for the tier 5 drug. We determined that the plan calculated your coinsurance correctly and no further reimbursement is required.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Zonisamide 25 milligram capsules. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Zonisamide has been prescribed for the treatment of essential tremor. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the Zonisamide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rybelsus 7 milligram tablets prescribed to treat type 2 diabetes mellitus. 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. Rybelsus was prescribed to treat type 2 diabetes mellitus.  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. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for an unknown diagnosis. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows you were still in the deductible stage of the Part D benefit when you purchased the Lidocaine. Your plans Evidence of Coverage states that you are responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined this drug was paid correctly and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100 micrograms powder for inhalation prescribed to treat chronic obstructive pulmonary disease. 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.Trelegy Ellipta 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 Ipratropium/Albuterol 2.5-0.5 milligrams/3 milliliter prescribed every six hours as needed for chronic obstructive pulmonary disease. 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 are diagnosed with chronic obstructive pulmonary disease. However, this drug is eligible for coverage under Medicare Part B. The Ipratropium/Albuterol is being used in a nebulizer that is covered by Medicare Part B durable medical equipment. Therefore, the drug may be covered by Medicare Part B.We determined that the plan is not required to cover Ipratropium/Albuterol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathioprine 50 milligram tablet prescribed for chronic progressive hypersensitivity pneumonitis. The Part D plan denied your 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.Your prescriber indicates that Azathioprine is prescribed for chronic progressive hypersensitivity pneumonitis. Medicare approved compendia does not support this drug for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitriol 0.25-microgram capsule prescribed daily for vitamin D deficiency. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. We also researched Medicare systems and reviewed the enrollment data available. The record shows you are diagnosed with vitamin D deficiency. However, this drug may be eligible for coverage under Medicare Part B. Treatment for vitamin D deficiency while on dialysis may be covered by Medicare Part B.We determined that the plan is not required to cover Calcitriol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec ODT 75 milligram tablet prescribed for migraines. 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. Nurtec 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 an off formulary exception for Tadalafil 5 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 a tiering exception request for Myrbetriq 24-hour extended-release oral 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. Myrbetriq is a brand drug on Tier 4 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 a tiering exception request for Dupixent 300 milligrams/2 milliliters to treat atopic dermatitis. 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.This drug is being 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.Our physician reviewer's opinion is that non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 200-milligram tablet to treat dyssomnia, hypersomnolence, and major depressive disorder. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 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. 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: Favorable

At issue is Coreg 10 milligram prescribed daily for hypertension. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records show the physician prescribed Coreg to treat your hypertension. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of the requested drug for your condition. Carvedilol oral tablets are indicated for the management of essential hypertension and may be used alone or in combination with other antihypertensive agents, especially thiazide-type diuretics.The records show that you cannot take other drugs on your plans formulary for your condition. Specifically, Carvedilol gave you worsening anxiety and tremors and your physician stated that Labetalol would not be a good medication for you and your conditions.A physician reviewed your appeal and determined that an exception can be granted to cover the drug that is not on your plans formulary. Therefore, the plan is required to cover Coreg.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 4 milligram orally disintegrating tablet prescribed for nausea. The Part D plan denied your 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.Your prescriber indicates that Ondansetron 4 milligram orally disintegrating tablets are prescribed for nausea. Medicare approved compendia does not support this drug for this condition except for chemotherapy induced, post-operative, or radiation induced nausea.A physician reviewed your appeal and determined that the plan is not required to cover Ondansetron.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lyumjev 100 unit/milliliter vial prescribed for diabetes, type 1. The Part D plan denied your requestWe 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 Lyumjev is being administered through an infusion pump in the home for treatment of diabetes. 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 drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover the Lyumjev. Please consider submitting this 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

At issue is Prolia 60 milligram per milliliter syringe. 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.Prolia is a biological product drug on Tier 4 of the plans formulary. There are no biological product 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 Nuzyra 150 milligram tablets prescribed for cutaneous mycobacterial infection. The Part D plan denied your 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.Your prescriber indicates that Nuzyra is prescribed for a skin and soft tissue infection due to mycobacterium chelonae. Medicare approved compendia does not support this drug for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Nuzyra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Vumerity DR 231 milligram capsules prescribed for multiple sclerosis. 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. Vumerity DR is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all 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. 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 Gabapentin 300 milligram tablet prescribed for low back pain and bilateral lower extremity paresthesia. 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 Gabapentin 300 milligram tablet prescribed for low back pain and bilateral lower extremity paresthesia. 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 Gabapentin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Solaraze 3 percent gel prescribed twice daily for other specified arthritis, unspecified site. 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 Solaraze to treat your other specified arthritis, unspecified site. 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 Solaraze.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Desvenlafaxine Succinate Extended Release 100-milligram Tablet 24-Hour to treat generalized anxiety disorder. The Part D plan denied the request. 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. 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.