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

At issue is Timoptic Ocudose 0.5% eye drops prescribed one drop twice a day for glaucoma.   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 prescriber has not indicated 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 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 Wixela Inhub 250/50 microgram inhaler prescribed as directed for chronic obstructive pulmonary disease. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Wixela Inhub 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 tiering exception request for Sinemet CR 25-100 milligrams tablets prescribed for Parkinsons disease. 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 brand name drug, as prescribed, is not on your plan formulary. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Esomeprazole Magnesium 40 milligram capsules prescribed for chronic migraine. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Esomeprazole Magnesium for chronic migraine. Your doctor further stated you had diagnoses of hypertension, asthma, lung disease, endometriosis, glaucoma, and food sensitivities. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not 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 Mycophenolate Mofetil 500 milligram tablets to treat autoimmune necrotizing myopathy associated with positive anti-HMGCR antibody. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Mycophenolate Mofetil 500 milligram tablets to treat your autoimmune necrotizing myopathy. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined  that the plan is not required to cover Mycophenolate Mofetil 500 milligram tablets because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Restasis (Cyclosporine) ophthalmic 0.05% emulsion to treat the enrollees condition. The Part D plan denied because there are no lower tier alternatives for your condition. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read 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.Restasis (Cyclosporine) ophthalmic 0.05% emulsion 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 Restasis (Cyclosporine) 0.05% ophthalmic solution is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acitretin 10 milligram capsule to treat Hailey-Hailey.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  We received a reconsideration request.  We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.  The 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

At issue is Pantoprazole sodium delayed release 40 milligram tablets prescribed for Barretts esophagus. The Part D plan denied your request for coverage under Medicare Part D because the manufacturer does not have a current registration with the Food and Drug Administration. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.According to the Food and Drug Administration, Pantoprazole sodium has a National Drug Code that is not eligible under Part D, because the manufacturer does not have a current registration for the drug. Therefore, we determined the plan is not required to cover the Pantoprazole sodium. 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 Dexilant 30 milligram delayed release oral capsule prescribed daily to treat Barretts esophagus, gastroesophageal reflux disease, and acute gastritis. The Part D Plan denied your request for a tiering exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Dexilant 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 Mavyret 100milligram/40 milligram tablet prescribed as directed to treat Hepatitis C infection, genotype type 1a. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 record shows that your doctor prescribed the Mavyret to treat your condition. Your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Mavyret because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Praluent Soln Auto-inj 75 milligrams/milliliter to treat coronary artery disease and hyperlipidemia. The Part D plan denied your request for a tiering exception. We received a reconsideration request.  We performed and 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. Praluent Soln Auto-inj is a biologic drug on Tier 3 of the plans formulary. There are no biologic 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 cover Praluent Soln Auto-inj because there are no biologic drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Favorable

You requested Dextroamphetamine- Amphetamine Extended Release 25 milligrams capsules prescribed two capsules daily for attention-deficit hyperactivity disorder. The Part D plan was unable to make a timely decision. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. The record shows the enrollee was previously misdiagnosed and has done well on the increased dose of 25 milligrams twice a day. Medicare approved compendia approves this dosage in certain cases.We determined that the plan is required to cover the Dextroamphetamine- Amphetamine Extended Release. The Medicare rules above have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 25 milligram injections prescribed weekly for type 2 diabetes with hyperglycemia. The Part D plan denied coverage. The plan requires step therapy criteria be met before covering some prescription drugs. If step therapy requirements are not met, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The plan requires a therapeutic trial and failure of Trulicity, Bydureon, or Byetta. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria for step therapy.A physician reviewed your appeal and determined that the plan is not required to cover Ozempic.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nuedexta 20-10 mg capsule to treat pseudobulbar affect.  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.In the Reconsideration appeal the prescriber provided relevant medical records.  The FDA label, available at Drugs@FDA.gov states:  NUEDEXTA is a combination product containing dextromethorphan hydrobromide (an uncompetitive NMDA receptor antagonist and sigma-1 agonist) and quinidine sulfate (a CYP450 2D6 inhibitor) indicated for the treatment of pseudobulbar affect (PBA).  Therefore the drug is being prescribed for a medically accepted indication.  The documentation does not satisfy the Plans coverage criteria.  However, the prescriber has indicated why all alternatives required by the Plan would likely not be as effective as the requested drug for you, or would likely cause adverse reaction(s). 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 Lidocaine Patch 5% prescribed for sciatic pain. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization requirements be met 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. Your medical records show your doctor prescribed Lidocaine Patch 5% to treat your condition. However, the Medicare approved compendia does 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 Lidocaine Patch 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligram tablets prescribed for the enrollees primary insomnia. 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 a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of primary insomnia. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trospium Chloride 20 milligram tablet  prescribed twice daily for overactive bladder. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.The records do not adequately show why you cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Trospium Chloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Repatha Sureclick Auto Injector 140 milligrams/milliliter to treat hyperlipidemia. The Part D Plan denied the request because your prescriber did not provide the detailed information that is required in order to approve the request for prior authorization. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Your medical records show your doctor prescribed Repatha Sureclick Auto Injector to treat your hyperlipidemia. The Medicare compendia approve the use of Repatha Sureclick for your condition. Your doctor has not provided detailed medical records indicating why all alternatives required by the plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met per Medicare rules.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Idhifa 100 milligram tablets prescribed daily for an enrollee with refractory acute myeloid leukemia. 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 a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The medical records show the doctor prescribed Idhifa to treat refractory acute myeloid leukemia. The enrollee was initially diagnosed with low risk myelodysplastic syndrome in 2016; treatment consisted of Nplate, Aranesp, and transfusions. The enrollee developed refractory disease around October 2019, and started Azacitidine and Venetoclax. The enrollees disease progressed to acute myeloid leukemia in August 2020. As of February 2021, the enrollees disease was progressing and two mutations, IDH2 mutation and FLT3 mutation (2 subclones), were identified. The enrollee was previously treated with decitabine, but it is not included in the current treatment regimen. As of March 1, 2021, the enrollees treatment regimen includes Idhifa and Xospata. Idhifa is Food and Drug Administration approved as an IDH2 inhibitor for relapsed/refractory acute myeloid leukemia and is supported by the National Comprehensive Cancer Network guidelines as a Category 1 recommendation. The Medicare approved compendia do support the use of this drug for the enrollees condition. According to the National Comprehensive Cancer Network, a clinical trial is a preferred option for relapsed/refractory acute myeloid leukemia. The provider has not cited any trials for the combination of drugs prescribed. However, there is no standard of care for relapsed/refractory acute myeloid leukemia, as implied by the National Comprehensive Cancer Network including a clinical trial as a preferred option. An exception to the plans coverage criteria is medically necessary for this enrollee. A physician reviewed your appeal and determined that the plan is required to cover Idhifa.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Xospata 40 milligram tablets prescribed as directed for an enrollee with refractory acute myeloid leukemia. 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 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. The medical records show the doctor prescribed Xospata to treat refractory acute myeloid leukemia. The enrollee was initially diagnosed with low risk myelodysplastic syndrome in 2016; treatment consisted of Nplate, Aranesp, and transfusions. The enrollee developed refractory disease around October 2019, and started Azacitidine and Venetoclax. The enrollees disease progressed to acute myeloid leukemia in August 2020. As of February 2021, the enrollees disease was progressing and two mutations, IDH2 mutation and FLT3 mutation (2 subclones), were identified. The enrollee was previously treated with decitabine, but it is not included in the current treatment regimen. As of March 1, 2021, the enrollees treatment regimen includes Idhifa and Xospata. Xospata is Food and Drug Administration approved for FLT3 mutation for relapsed/refractory AML and is supported by the National Comprehensive Cancer Network guidelines as Category 1 recommendation. The Medicare approved compendia do support the use of this drug for the enrollees condition. According to the National Comprehensive Cancer Network, a clinical trial is a preferred option for relapsed/refractory acute myeloid leukemia. The provider has not cited any trials for the combination of drugs prescribed. However, there is no standard of care for relapsed/refractory acute myeloid leukemia, as implied by the National Comprehensive Cancer Network including a clinical trial as a preferred option. An exception to the plans coverage criteria is medically necessary for this enrollee. A physician reviewed your appeal and determined that the plan is required to cover Xospata.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nexium prescribed for gastroesophageal reflux disease. 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. We also researched Medicare systems and reviewed the enrollment data available. The record shows your prescriber is requesting brand name Nexium, as generic does not control your symptoms. A physician reviewed your appeal and determined that the plan is not required to cover the Nexium. Nexium is not on your plans formulary and the records do not show why you cannot take other drugs on the plans formulary for your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chlordiazepoxide-Clidinium 1milligram capsule to treat an unspecified medical diagnosis. The Part D plan denied the request. 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 plan denied the request for coverage of Chlordiazepoxide-Clidinium to treat the provided diagnosis because the plans Medicare Part D drug plan cannot cover drugs classified as being part of the Food and Drug Administrations Drug Efficacy Study Implementation (DESI) program. These drugs are considered to be Less than Effective per Food and Drug Administrations review.A physician reviewed your appeal and determined that the plan is not required to cover Chlordiazepoxide-Clidinium.