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

At issue is Dupixent 300 milligram per 2 milliliter syringe prescribed daily for atopic dermatitis. 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. Dupixent is a brand drug that is not on the plans formulary. Medicare has already granted a formulary exception for the drug. Per Medicare rules, a tiering exception cannot be allowed for a drug that is not on the plans formulary. 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 Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temazepam 30 milligram tablets prescribed as 30 tablets for 30 days for insomnia. The Part D plan denied the request. We received an expedited 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. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia supports this drug for short term insomnia generally of 7-10 days duration. It is also to be used or avoided in older adults as potentially inappropriate. There was no indication that medication with less risk in older adults was tried or reasons a non-high risk medication might be contraindicated. Therefore, the prior authorization requirements were not met.   Our Physician Reviewer determined that the plan is not required to cover Temazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patches prescribed for pain management due to multiple rib fractures. 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 available. A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine patch because pain management due to multiple rib fractures is not a medically accepted indication to use this drug.The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, the requested drug does not meet the definition of a Medicare Part D drug and is therefore not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Mayzent 2 milligram tablet prescribed for multiple sclerosis. The Part D plan denied your request. 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. We also researched Medicare systems and reviewed the enrollment data available. The record shows Mayzent is being prescribed for multiple sclerosis. The Medicare approved compendia support the use of the requested drug for your condition. However, the drug is not one that is covered on your plan's formulary or their list of covered drugs. You did not indicate that all covered Part D drugs on any tier of the plan's formulary would not be as effective for the enrollee as the requested non-formulary drug, and/or would have adverse effects.The plan is not required to cover the drug at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20 milligram tablets prescribed to treat erectile dysfunction. The Part D plan denied your request because drugs to treat erectile dysfunction are not covered under Medicare Part D. 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. Medicare has excluded Part D coverage of drugs when being used specifically to treat erectile dysfunction. A physician reviewed your appeal and determined that the plan is not required to cover the Sildenafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram/milliliter prescribed for one injection every 28 days for hyperlipidemia. The Part D Plan denied your request for a tiering exception because there were no other biologic drugs of the same type on lower cost sharing tiers. The plan was unable to offer a lower cost share for this 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. We also researched Medicare systems and reviewed the enrollment data available. Repatha is a biologic drug on Tier 3 of the plans formulary. The prescriber statement shows the drug was requested to treat hyperlipidemia. We asked our physician reviewer to determine whether the plan was correct in denying the request for a tiering exception for Repatha. 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. Our physician reviewer's opinion is that tiering exception criteria are not met. Medicare rules permit a plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. The tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating your condition. Therefore, our decision is the plan is not required to provide a tiering exception for Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuvail Solution prescribed for brittle nail syndrome. The Part D plan denied your request because the drug at issue was not Food and Drug Administration approved. 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 record shows your physician prescribed Nuvail Solution for brittle nail syndrome. The drug at issue is not Food and Drug Administration approved. Therefore, the drug cannot be considered a Part D benefit.We determined that the plan is not required to cover the Nuvail Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubelvy 100 milligrams for migraine disorder. 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 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 physician submitted a supporting statement. The supporting statement indicated you could not take triptans due to arrhythmias. However, your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Ubelvy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligrams/2 milliliter injection prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other biologics on a lower cost-sharing tier to treat your condition. 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.Dupixent is a brand biologic on Tier 3 of the plans formulary. There are no other brand biologics of the same type on the lower cost sharing tiers to treat your condition. Therefore, this biologic is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tobramycin Inhalation 60 milligrams prescribed via nebulizer every-other-month for bronchiectasis. 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 Tobramycin Inhalation to treat your bronchiectasis. However, the Medicare approved compendium 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 Tobramycin Inhalation because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitriol 0.25 micrograms prescribed for secondary hyperparathyroidism due to chronic kidney disease, stage IV. 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 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 your doctor prescribed the medication for your diagnosis of secondary hyperparathyroidism due to chronic kidney disease, stage IV. Medicare records indicate you are covered under an end-stage renal disease facility plan beginning January 1, 2020. Payment for the drug at issue is considered bundled into the prospective payment to the end-stage renal disease facility and is therefore not a covered Part D benefit.We determined that the plan is not required to cover Calcitriol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Motegrity 2 milligram tablets prescribed for irritable bowel syndrome with diarrhea and diarrhea due to Parkinsons disease. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. 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 submitted documentation indicates your doctor prescribed the drug for irritable bowel syndrome with diarrhea and diarrhea due to Parkinsons disease. The Medicare approved compendia do not support this is a medically accepted indication. 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

At issue is a tiering exception request for Mesalamine 4 gram/60 milliliter enema to treat the enrollees condition. 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.Mesalamine 4 gram/60 milliliter enema is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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

At issue is Albuterol sulfate nebulizer solution 2.5 milligrams/5 milliliters (0.083%). 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 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 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.   A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mavyret 100milligram/40 milligram tablets to treat Hepatitis C infection with compensated cirrhosis, genotype type 3a. 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 documentation satisfies the plans coverage criteria. Medical records received with the reconsideration request support the patient was previously treated with Interferon. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica 150 milligram tablets to treat severe neuropathic pain associated with ulnar neuropathy and cervical radiculopathy. 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 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. 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Lyrica 150 milligram tablets. A physician reviewed your appeal and determined that the plan is not required to cover Lyrica 150 milligram tablets because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Belbuca 750 micrograms Buccal Film to treat chronic 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.Your medical records show that you doctor prescribed Belbuca Buccal Film for your chronic pain. Belbuca 750 micrograms Buccal Film is a brand drug on Tier 4 of the plans formulary. The prescriber has stated that all lower tiered drugs to treat the condition have been tried and failed or provided reasons why they would likely not be as effective as the requested drug. In a letter dated February 26, 2021, the plan approved the tier exception request to lower the drug to a tier 3 copay. Therefore, this drug is eligible for a tiering exception.  Our Physician Reviewer's opinion is that tiering exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a 90-day supply of Alprazolam 1 milligram tablets to be taken two times a day for generalized anxiety disorder. The Part D plan denied your request for a 90-day supply because Alprazolam is a specialty drug limited to a 30-day supply by 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. This includes the case file from the plan and any information submitted at the reconsideration level. Alprazolam is listed on the Part D plans formulary with a quantity limit of a recurring 30-day supply. An exception to the quantity limit criteria cannot be granted. A physician reviewed your appeal and determined that the plan is not required to cover a 90-day supply of Alprazolam.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine Hydrochloride urethral/mucosal 2% gel prescribed as directed. 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 reconsideration request form shows the enrollee was prescribed Lidocaine Hydrochloride urethral/mucosal 2% gel for groin pain after radiation treatment. However, the reconsideration request form has not been signed by the prescribing physician and the documentation does not contain any medical records to confirm the enrollees diagnosis. There is insufficient documentation to determine if the Medicare approved compendia 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 Lidocaine Hydrochloride urethral/mucosal 2% gel.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Disopyramide Phosphate 150 milligrams prescribed for paroxysmal atrial fibrillation. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.A provider statement received at the reconsideration level answers 'yes' to the question: The American Geriatrics Society identifies the use of this medication as potentially inappropriate in older adults, meaning it is best avoided, prescribed at reduced dosage, or used with caution or carefully monitored. Does the benefit of therapy with this prescribed medication outweigh the potential risks for this patient? Therefore, this prior authorization requirement is satisfied. The Medicare approved compendia satisfy an exemption to the prior authorization requirement for FDA-approved indications as the drug is being used for a medically accepted indication.A physician reviewed your appeal and determined that the drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20 milligram tablet for right ventricular support post left ventricular assist device implant. 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 Vimpat 150 milligrams tablets prescribed as directed for seizures. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. 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. This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. 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 Vimpat. A tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 30 milligram capsule to treat sleepiness due to narcolepsy and obstructive sleep apnea. 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 prescriber changed the diagnosis to attention deficit disorder in the request for reconsideration. Relevant medical records were requested but not provided to support the diagnosis of attention deficit disorder.   The use of the requested drug to treat the provided diagnosis, narcolepsy and obstructive sleep apnea, 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.