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

At issue is Paliperidone Extended Release 6 milligram tablet prescribed for schizoaffective disorder. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read 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. Your prescriber indicates they prescribed Paliperidone for schizoaffective disorder. The medical records (office note of July 06, 2021) support this diagnosis, and this is a medically accepted indication per Medicare approved compendia. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Approval for Paliperidone Extended Release in schizoaffective disorder can be made without the trial of other treatment per the plans prior authorization criteria. The plan's coverage criteria has been met.   A physician reviewed your appeal and determined that the plan is required to cover Paliperidone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Fluoxetine Hydrochloride 60 milligram tablets prescribed for major depressive disorder. 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. Fluoxetine Hydrochloride 60 milligram tablet is not included in the plans formulary. During this review, a request was submitted to the prescriber to address the alternative medications included in the plans formulary and to provide supporting medical records. The prescriber did not respond to the request. 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, the formulary exception criteria have not been satisfied by the available documentation. 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 Sutab 1.479-0.225-8.188 gram tablet. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We requested additional information from the prescriber but did not get a response. In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, documentation supporting a medically accepted indication are required. This information was requested from the prescriber and we did not receive information that could answer these medical necessity issues.  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 Sutab.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Orencia Clickject 125 milligram/milliliter auto-injector pen prescribed for generalized morphea and scleroderma. The Part D plan denied the request because the diagnosis submitted did not support a medically accepted indication. In addition, the requested drug is not listed on the plans formulary. 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 Orencia Clickject was prescribed to treat generalized morphea and scleroderma. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. Therefore, Orencia Clickject is not eligible for coverage under Medicare Part D. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules. Since the drug is not eligible for coverage under Part D, the plans formulary exception requirements are not applicable to this review.A physician reviewed your appeal and determined that the plan is not required to cover Orencia Clickject.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kisqali 600-milligram Daily Dose Tablet to treat malignant neoplasm of unspecified site of right female breast. 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.We asked your prescriber to send us medical records. However, we did not receive the documentation.Your 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. Prior treatment with anastrazole is documented in the medical record.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 Clindamycin Phosphate 1% solution prescribed twice daily for hidradenitis suppurativa. 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 Clindamycin Phosphate 1% solution to treat the enrollees hidradenitis suppurativa. 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 Clindamycin Phosphate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate 2.5 milligrams per 3 milliliters vial for nebulization prescribed to treat asthma. The Part D Plan denied the appeal 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 record shows Albuterol Sulfate is being administered through a nebulizer 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 the Albuterol Sulfate. 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

The enrollee requested Freestyle Libre 14 day sensor prescribed for diabetes mellitus with neuropathy. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is not required to cover the Freestyle Libre 14 day sensor because it is not considered a medical supply directly associated with the injection of insulin. Although, this supply is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. This decision does not address the medical necessity or appropriateness of the supply. It only establishes that payment cannot be made under the Medicare Part D benefit
Appeal type: Prescription Drug
Decision: Favorable

At issue is Rebif 44 microgram/0.5 milliliter subcutaneous pen injector prescribed for relapsing remitting 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. This includes the case file from the plan, and any records submitted at the reconsideration level. Your prescriber indicates they prescribed Rebif 44 microgram/0.5 milliliter pen injector for relapsing remitting multiple sclerosis and this is for continuation of care.  The enrollee has been on the requested drug since 2015. Supporting medical records were provided. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plan's coverage criteria has been met.  A physician reviewed your appeal and determined that the plan is required to cover Rebif.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz XR 11 milligram tablet prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tramadol Hydrochloride 50 milligram tablet prescribed 45 tablets per 30 days for chronic pain. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber indicates that Tramadol 50 milligram tablet with a quantity of 45 tablets per 30 days is requested to treat chronic pain.   The prescriber was asked to indicate the morphine milligram equivalent dose warranted to adequately manage the enrollee's pain or to potentially have on hand at their disposal.  In a statement dated 8/9/2021, the prescriber stated that a morphine milligram equivalent of 200 mg/day would be warranted.  The plan stated that this would be the new limit at which the enrollee's opioid prescriptions would be subject to.  Tramadol 50 milligram tablet, 45 tablets per 30 days, in addition to the enrollee's other opioid prescriptions on hand, would exceed the morphine milligram equivalent of 200 milligrams/day. The documentation does not support a medical necessity for an exception to the plans quantity limit.  A physician reviewed your appeal and determined that the plan is not required to cover Tramadol Hydrochloride 50 milligram tablet with a quantity of 45 tablets per 30 days.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a coverage request for Testosterone Cypionate 200 milligram/milliliter prescribed for testicular hypofunction. 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. We asked prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested.The documentation shows Testosterone Cypionate 200 milligram/milliliter prescribed for testicular hypofunction. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not include medical records to support that the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Testosterone Cypionate. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cinacalcet Hydrochloride 30 milligram tablets. 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.  In the reconsideration appeal medical records were requested.  No medical records were provided.  The documentation indicates that Cinacalcet Hydrochloride has been prescribed for the treatment of secondary hyperparathyroidism associated with chronic kidney disease in an enrollee not currently on dialysis. 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 Dronabinol 2.5 milligram capsules prescribed as directed for headache and anorexia. 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 headache and anorexia. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Injectafer 750 milligram per 15 milliliter intravenous solution. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Injectafer, which is a mineral product, has been prescribed for the treatment of iron deficiency anemia. However, prescription vitamin and mineral products are excluded from coverage under Medicare Part D. Therefore, the Injectafer is not eligible for coverage under Medicare Part D. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Toujeo Solostar 300 units per milliliter pen prescribed 100 units per day for type 2 diabetes mellitus. 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. Specifically, we asked for records to show why other medications on the plan's formulary would not work. We received the documentation and included it in our review.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 Toujeo Solostar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Azathioprine 50 milligram tablet prescribed for neurosarcoidosis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows Azathioprine 50 milligram tablet was prescribed for neurosarcoidosis. 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 Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix 50 microgram/0.5 milliliter suspension reconstituted prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Shingrix is a biological product drug on Tier 3 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 Alosetron Hydrochloride 0.5 milligram prescribed twice daily for irritable bowel syndrome with diarrhea. 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 Alosetron Hydrochloride 0.5 milligram to treat irritable bowel syndrome with diarrhea in a male enrollee. 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 Alosetron Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Canasa 1000 milligram suppositories prescribed to treat itching, bleeding and pus from the rectum associated with irritable bowel syndrome with diarrhea. The Part D plan denied the appeal request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Canasa 1000 milligram suppositories to treat itching, bleeding, and pus from the rectum associated with irritable bowel syndrome with diarrhea. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Canasa 1000 milligram suppositories.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Aubagio 14 milligram tablets prescribed for relapsing-remitting 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. This includes the case file from the plan and any information submitted at the reconsideration level. Aubagio is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient 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. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Olumiant 2 milligram tablet prescribed for rheumatoid 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. 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 all drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to Olumiant.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bystolic 2.5 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 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. Bystolic is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed 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 Clinolipid Emulsion 20% prescribed for malnutrition with a functioning gastrointestinal tract. 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. 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 prescriber does not indicate why the other alternative on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Clinolipid Emulsion 20%.