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

You requested Promacta 50 milligram tablet prescribed for the treatment of thrombocytopenia in adult recipient of an allogeneic hematopoietic stem cell transplant. 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 records show you prescribed Promacta 50 milligram tablet to treat the enrollees thrombocytopenia following allogenic hematopoietic stem cell transplantation. 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 Promacta 50 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulance 3 milligram tablet to treat chronic idiopathic constipation. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read all documentation submitted. This includes the any information submitted at the reconsideration level.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 Levalbuterol 0.63 milligram/3 milliliter inhalation solution prescribed for morbid obesity with alveolar hypoventilation. 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.The medical records indicate you are using Levalbuterol delivered via a nebulizer in your home. Drugs used via nebulizer in an enrollees home may be covered under Part B. Therefore, this is not eligible for Part D coverage.We determined that the plan is not required to cover Levalbuterol inhalation solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pulmicort 0.25 milligram/2 milliliters inhalation solution prescribed for your condition. The Part D Plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received a reconsideration request.  We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. Your doctor prescribed Pulmicort to treat your condition. The Medicare approved compendia support the use of this drug for your condition. However, the drug is administered with a nebulizer. Based on the information provided, the drug is eligible for Part B coverage.  Therefore, the drug is not eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is not required to cover Pulmicort.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine/Prilocaine 2.5/2.5 percent cream prescribed to treat neuropathic pain and polyneuropathy. 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. Medicare approved compendia do not support the use of the drug for your condition.  The documentation does not satisfy the plans coverage criteria. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine/Prilocaine cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Revlimid 5 milligram capsule to treat cutaneous lupus erythematosus. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. The case was auto-forwarded by the planWe 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: Unfavorable

At issue is a tiering exception request for Linzess 145-microgram capsule to treat the enrollees constipation. 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.Linzess is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Belladonna Alkaloids Opium Suppositories prescribed for rectal pain. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The Medicare approved compendia do not support the use of the drug for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Belladonna Alkaloids Opium Suppositories.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 2 milligram tablets to treat mixed hyperlipidemia. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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

At issue is to treat Ipratropium Bromide .02% nebulizer solution for acute on chronic and hypercapnic respiratory failure. The Part D plan denied the request stating that the drug could be covered under Medicare Part B. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Adderall 15 milligram tablets. 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 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.While the progress notes submitted at reconsideration include a new diagnosis of attention deficit hyperactivity disorder, the submitted documentation indicates that Adderall was actually prescribed for excessive daytime sleepiness due to obstructive sleep apnea with severe hypopneas. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of excessive daytime sleepiness due to obstructive sleep apnea with severe hypopneas. Therefore, the drug is being used for a non-medically accepted indication and 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 Adderall.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Jardiance 10 milligram tablet daily to treat the enrollees condition. 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.Jardiance 10 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

You requested Afinitor 10 milligram tablet prescribed for metastatic estrogen receptor positive, human epidermal growth factor receptor 2 negative left breast 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 records show you prescribed Afinitor 10 milligram tablet to treat the enrollees metastatic estrogen receptor positive, human epidermal growth factor receptor 2 negative left breast cancer. The records submitted indicate that the enrollee is post-menopasual and will be using Afinitor in combination with Letrozole. Afinitor will not be utilized with Exemestane or Faslodex as they have been tried and failed with this enrollee. Tamoxifen for the post-menopausal enrollee is not the standard of care as it can increase risk of cataracts and thrombotic events. This enrollee has ocular muscle involvement with diplopia, using Tamoxifen could result in worsening ocular function and thrombosis. Therefore, Letrozole is considered safest to be used with Afinitor for this enrollee.  An oncologist reviewed your appeal and determined that the plan is required to cover Afinitor 10 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine 8 milligrams sublingual to treat long-term use of opioid analgesic, cervicalgia and low back pain. 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.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.
Appeal type: Prescription Drug
Decision: Favorable

You requested Vemlidy 25 milligram tablet to treat the enrollees condition. 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. We also researched Medicare regulations and Medicare approved compendia.The record shows the enrollee was prescribed Vemlidy 25 milligram tablets for human immunodeficiency virus. The medical records show it is taken with least one other medication for this condition, so it is not being used as monotherapy.  The following citation in American Hospital Formulary Service Drug Information (AHFS-DI), a Medicare approved compendium, supports the use of the requested drug for your condition: Vemlidy also is used for the treatment of human immunodeficiency virus infection. Therefore, it is considered a medically accepted indication.The documentation does satisfy the plans coverage criteria. The plans coverage criteria state that you need to have a Food and Drug Administration approved indication. Therefore, an exception to the plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Braftovi 75 milligram capsules prescribed as directed for cholangiocarcinoma. 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 the physician prescribed Braftovi for an enrollee with cholangiocarcinoma. The enrollee was previously treated with Gemcitabine and Abraxane. However, the enrollee developed side effects and pancytopenia, which caused treatment delays with this regimen. Molecular testing was completed and showed BRAF V600E mutation. The National Comprehensive Cancer Network Guidelines state that for BRAF positive cholangiocarcinoma, BRAF dual inhibition can be done with Dabrafenib/Trametinib. In addition, the provider submitted a journal article from the Lancet showing a study using a combination of Dabrafenib/Trametinib for the treatment of cholangiocarcinoma. The prescriber has not provided the reason why the compendia-supported BRAF inhibitor treatment of Dabrafenib/Trametinib for cholangiocarcinoma cannot be used for this enrollee. The Medicare approved compendia do no support the use of Braftovi for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover the Braftovi.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sirolimus 0.5 milligram tablets prescribed for immunosuppression following a liver transplant. 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. The submitted documentation indicates your doctor prescribed Sirolimus for immunosuppression following a liver transplant. The Medicare approved compendia do not support the use of this 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

You requested a lower cost tiering exception for Oxcarbazepine 300 milligram tablets prescribed for bipolar 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.Oxcarbazepine is a generic drug on Tier 3 of the plans formulary. The prescribing physician has not sufficiently addressed why all of the generic drugs of the same type on the lower tiers of the plans formulary to treat the enrollees condition have been tried and failed, or are contraindicated. A physician reviewed your appeal and determined that the plan is not required to cover the Oxcarbazepine tablets at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipratropium bromide/albuterol sulfate 0.5/2.5 (3) milligrams/3 milliliters prescribed as directed via nebulizer 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.The record shows the doctor prescribed Ipratropium bromide/albuterol sulfate for chronic obstructive pulmonary disease. However, this drug is eligible for coverage under Medicare Part B. Medicare Part B covers this drug for obstructive pulmonary disease, when used with a nebulizer in the home (or in an assisted living facility). Medicare Part D cannot pay for drugs that are covered by Medicare Part B.We reviewed your appeal and determined that the plan is not required to cover Ipratropium bromide/albuterol sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 20 milligram tablets prescribed to treat bipolar disorder current episode depressed, mild. 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 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 on the plans Specialty Tier. Specialty Tier drugs are not available for a tiering exception per Medicare rules.  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 coverage for Enbrel 50 milligram per milliliter subcutaneous injection pen prescribed for psoriasis vulgaris and psoriatic arthritis. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis Emulsion 0.05% to treat your dry eyes. The Part D plan denied the request. The requested drug is not on the plans formulary. We received an expedited 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 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

At issue is Nuedexta prescribed for your pseudobulbar affect. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited 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.The documentation supports the drug was prescribed for your diagnosis of pseudobulbar affect. However, you do 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: Unfavorable

You requested Colestid 1 gram tablets prescribed for postcholecystectomy syndrome. 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 submitted documentation indicates your doctor prescribed Colestid for postcholecystectomy syndrome and post gallbladder diarrhea. A statement on appeal indicates the prescribed diagnosis should be changed to toxic gastroenteritis. The Medicare approved compendia do not support the use of the drug for any of these conditions. 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

You requested Colchicine 0.6 milligram tablets prescribed to treat inflammatory polyarthritis with a consideration of pseudogout. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. 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 Colchicine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Testosterone Gel. 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 prescribers statement along with medical records that support a diagnosis. However, we did not receive the documentation.Testosterone is a generic drug on Tier 3 of the plans formulary. Your doctor did not address why all alternative lower-tier medication on the plans formulary would not work for you. All generic drugs on lower tiers have not been tried. 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.