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

At issue is a request for coverage of Xifaxan 550 milligram tablets. The Part D plan denied the request for coverage because there was insufficient clinical information from the prescriber to determine the medical necessity for the drug. 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.At reconsideration, the prescriber has indicated that Xifaxan was prescribed for the treatment of small intestinal bacterial overgrowth. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Uloric 40 milligram tablet 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 plan submitted documentation that shows the enrollee was in the initial coverage stage of the Part D benefit when this drug was purchased. We reviewed the plan's Evidence of Coverage. The enrollees copay for a tier 3 drug in the initial coverage stage for a 60 day supply is 65 percent coinsurance or $80 maximum charge. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Vyzulta 0.024% ophthalmic solution prescribed for the treatment of open-angle glaucoma. 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.Vyzulta is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient 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. 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 Repatha 140-milligram/milliliter injection prescribed for heterozygous familial hypercholesterolemia. 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 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.Repatha is a biologic on Tier 3 of the plans formulary. There are no other biologics of the same type on the lower cost sharing tiers. Therefore, this biologic is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 120-milligram tablets prescribed for hypothyroidism. 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 drug at issue is not Food and Drug Administration approved. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Intron A 18-million units/3-milliliter infusion solution prescribed for Peyronies disease. 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 drug at issue is an infusion drug dispensed to and administer by the prescriber. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent adhesive patch prescribed to treat the enrollee with pain associated with multiple closed rib fractures and traumatic pneumothorax. 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 Lidocaine 5 percent adhesive patch to treat pain associated with multiple closed rib fractures and traumatic pneumothorax. 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 Lidocaine 5 percent adhesive patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cresemba 186 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 Cresemba has been prescribed for antifungal aspergillosis prophylaxis in an enrollee who is an immunocompromised state due to the presence of acute myeloid leukemia and the treatment for the condition. 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Durolane 60 milligram/3 milliliter prefilled syringe. 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. Durolane is an injectable gel the Food and Drug Administration has approved as a medical device that relieves the pain of knee or hip osteoarthritis. Since this is considered a device, it is not eligible for Part D benefits. It may be covered under Part B benefits.  We have determined that the plan is not required to cover Durolane.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omega 3-Acid Ethyl Esters 1 gram prescribed for hypertriglyceridemia. 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 ordered Omega 3-Acid Ethyl Esters to treat hypertriglyceridemia. The medical records provided, office note July 15, 2021, do not support this diagnosis. The diagnosis in the medical record is not a medically accepted indication.A physician reviewed the appeal and determined that the plan is not required to cover Omega 3-Acid Ethyl Esters.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cresemba 186 milligram capsule prescribed two daily for antifungal prophylaxis in patient with acute myeloid leukemia. 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 shows the doctor prescribed Cresemba for the enrollees antifungal prophylaxis. 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 Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Tymlos 3120 micrograms per 1.56 milliliters solution pen injector prescribed to treat osteoporosis. 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 Tymlos 3120 micrograms per 1.56 milliliters solution pen injector to treat the male enrollee with osteoporosis. Upon redetermination, the Part D plan denied the request stating that the plans prior authorization requirements were not met. 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 Tymlos 3120 micrograms per 1.56 milliliters solution pen injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligram/2 milliliter prefilled syringe prescribed for idiopathic urticaria. 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 prescriber indicates Dupixent 300 milligram/2 milliliter prefilled syringe is prescribed for idiopathic urticaria. However, 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 Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix 50 microgram/.5 milliliter suspension prescribed for vaccination. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 the enrollee was still in the deductible stage of the Part D benefit when the vaccine was administered at the pharmacy. The plans Evidence of Coverage states that enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined the amount the enrollee paid was applied to the deductible and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nulojix 250 milligram for solution. 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 an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted, including 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.Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300-milligrams/2-milliliters Subcutaneous Injection to treat atopic dermatitis. The Part D plan denied the request. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. 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. 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 Xifaxan 550 milligram tablet prescribed for intestinal failure and small intestinal bacterial overgrowth. 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. Xifaxan 550 milligram tablet is prescribed for intestinal failure and small intestinal bacterial overgrowth. However, 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epidiolex 100 milligrams per milliliter oral solution prescribed to treat the enrollee with epilepsy, unspecified. 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 Epidiolex 100 milligrams per milliliter oral solution to treat epilepsy, unspecified. 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 Epidiolex 100 milligrams per milliliter oral solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligram extended release 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. 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 a request for coverage of Tadalafil 20 milligram tablets. The Part D plan denied the request for coverage because the drug was not on the formulary and the documentation did not support a formulary 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 submitted medical records/progress notes indicate that Tadalafil has been prescribed to treat pulmonary hypertension, World Health Organization (WHO) Group 5. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug 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. 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 Medicare Part D, a formulary exception is not relevant to this review. 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 Buprenorphine Hydrochloride 8 milligram sublingual tablet prescribed for chronic pain syndrome in an enrollee with malignant neoplasm of the breast with metastasis to the brain. 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. Buprenorphine Hydrochloride 8 milligram sublingual tablet is prescribed for chronic pain syndrome in an enrollee with metastatic cancer. However, 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 Buprenorphine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acetylcysteine 20 percent vial prescribed three milliliters every four to six hours via nebulizer. 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 record shows Acetylcysteine 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 Acetylcysteine. Please submit 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

At issue is Soliloquy 100-units-33micrograms/milliliter Pen to treat Type 2 diabetes mellitus. The Part D plan denied the request. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you.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 Zolpidem 10-milligram tablet to treat insomnia, unspecified. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. This drug is considered a high-risk medication in older enrollees. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed, with support of medical records, the issues regarding this high-risk medication, and why alternative safer medications, in the plan's formulary, could not be used. 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 Armodafinil 50-milligram tablet to treat somnolence, Parkinsons disease, and excessive drowsiness. 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted conditions.  As such, 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 Sildenafil 20 milligram tablet prescribed for World Health Organization group 2 pulmonary 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 documentation shows Sildenafil was prescribed to treat World Health Organization group 2 pulmonary hypertension. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. 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.A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil.