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

At issue is a request for coverage of Aranesp 500 microgram per milliliter prefilled subcutaneous injection syringe prescribed for the treatment of anemia secondary to myelodysplastic syndrome with multilineage dysplasia. 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. The plan has authorization requirements that must be met before coverage of this medication will be approved. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Xermelo 250 milligram tablets prescribed for diarrhea associated with carcinoid syndrome. 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 submitted documentation indicates the prescriber originally ordered Xermelo for diarrhea associated with carcinoid syndrome, not in combination with a somatostatin analog. On appeal, the prescriber indicated a somatostatin analog would be added to be used in conjunction with Xermelo. However, the progress notes submitted do not indicate the enrollees condition is inadequately controlled by the use of a somatostatin alone. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 a request for coverage of Pregabalin 25 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 Pregabalin has been prescribed for the treatment of chronic back pain due to spinal cord narrowing. 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 Trulicity 0.75 milligram/0.5 milliliter pen injector prescribed for type 2 diabetes mellitus with hyperglycemia. 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.Trulicity is a biologic on Tier 3 of the plans formulary. There are no 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 a formulary exception request for Vumerity 231 milligram direct release capsules prescribed for multiple sclerosis. 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 prescriber submitted medical records and a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Vumerity.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 20 milligram tablets prescribed for major depressive disorder. 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 submitted documentation indicates the prescriber ordered Latuda for major depressive disorder. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 Ondansetron 4 milligram tablets prescribed for nausea associated with kidney stone pain. 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 submitted documentation indicates the prescriber ordered Ondansetron for nausea associated with kidney stone pain. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 Nuvigil 150 milligram tablets prescribed for idiopathic hypersomnia. 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 submitted documentation indicates the prescriber ordered Nuvigil for idiopathic hypersomnia. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 Esbriet 267 milligram tablets prescribed for idiopathic pulmonary fibrosis. 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 records 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 enrollee needs this medication. We did not receive the documentation requested. The medical records show the prescriber ordered Esbriet to treat idiopathic pulmonary fibrosis. The 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.A physician reviewed the appeal and determined that the plan is not required to cover Esbriet. 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 Buprenorphine Hydrochloride 2 milligram sublingual tablets prescribed for chronic pain. 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 submitted documentation indicates the prescriber ordered Buprenorphine Hydrochloride sublingual tablets for chronic pain. The Medicare approved compendia do not support the use of the drug at issue, in sublingual tablet form, for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 a request for coverage of Sildenafil Citrate 20 milligram tablets. 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 medical records indicate that Sildenafil Citrate has been prescribed for the treatment of severe secondary pulmonary hypertension. However, the Medicare approved compendia do not contain any citations to support the use of 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 Lidocaine 5% patch prescribed for chest wall and rib pain subsequent to a fall. 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 submitted documentation indicates the prescriber ordered Lidocaine 5% patch for chest wall and rib pain subsequent to a fall. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 a request for Granisetron HCL one milligram tablet prescribed as needed for chronic nausea. 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 Granisetron HCL to treat the enrollees nausea. 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 Granisetron HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atorvastatin 40 milligram capsules prescribed for prophylaxis against stroke. The case was auto-forwarded by the plan.  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 you need this amount of the medication. We did not receive the documentation requested. The submitted documentation indicates the prescriber ordered Atorvastatin for prophylaxis against stroke. The prescriber ordered two capsules per day; however, the plans allowance is one capsule per day. The submitted documentation does not support why an exception to the plans quantity limit is medically necessary. A physician reviewed the appeal and determined that the plan is not required to cover the Atorvastatin, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Dextroamphetamine-Amphetamine ER 20 milligram capsules prescribed for the treatment of attention deficit hyperactivity 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. This includes the case file from the plan and any information submitted at the reconsideration level. Dextroamphetamine-Amphetamine ER is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the preferred formulary alternative drug, Atomoxetine capsule, 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 Lamotrigine ER 100 milligram tablet prescribed twice daily for mood disturbance. The Part D plan denied the request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The medical records support the doctor prescribed Lamotrigine ER to treat the enrollees mood disturbance. 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 Lamotrigine ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for Modafinil 100 milligram tablet prescribed daily for insomnia. 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 Modafinil to treat the enrollees insomnia. 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 Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nubeqa 300 milligram tablets prescribed for metastatic castration naive prostate cancer. 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 the prescriber ordered Nubeqa to treat metastatic castration naive prostate cancer. However, the Medicare approved compendia do not support the use of this drug for your condition. There were no Medicare approved journal articles submitted to support the use of Nubeqa for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Nubeqa.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Uloric 40 milligram tablet prescribed daily for gout. 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 medical records show the physician prescribed Uloric to treat your gout. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of the requested drug for your condition. Febuxostat (Uloric) is indicated for the management of chronic hyperuricemia in adult patients with gout who have an inadequate response to a maximally titrated dose of Allopurinol, who are intolerant to Allopurinol, or for whom treatment with Allopurinol is not advisable .The records show that the enrollee cannot take other drugs on the plans formulary for their condition. Specifically, the physician states the enrollee tried Probenicid and had an immediate loss of control of the enrollees gout. The enrollee also tried Allopurinol but could not tolerate.A physician reviewed the appeal and determined that an exception can be granted to cover the drug that is not on the plans formulary. Therefore, the plan is required to cover Uloric.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 25 milligram tablet prescribed daily. 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. Myrbetriq is a brand drug on Tier 4 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 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 a tiering exception request for Wegovy 0.25 milligram per 0.5 milliliter subcutaneous injection pen. 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. Although the enrollee has stated that Wegovy is being used to treat diabetes, the only Food and Drug Administration (FDA)-approved use for the brand name drug Wegovy is weight loss. Drugs when used for weight loss are excluded from Part D coverage. Excluded medications are not eligible for a tier exception. Furthermore, Wegovy is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to grant a lower-cost tiering exception for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Tobrex 0.3% ophthalmic solution prescribed for eye infection. 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 requested additional documentation from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed. However, we did not receive the requested information.The submitted documentation did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Tobrex.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Forteo 620 microgram/2.8-milliliter injectable solution prescribed for the enrollees osteoporosis. 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 records submitted at the reconsideration level. The medical records support the doctor prescribed Forteo to treat the enrollees osteoporosis. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided shows the enrollee has satisfied the plan's coverage criteria. The prescriber submitted a statement to support the enrollee was prescribed Forteo to treat the enrollees osteoporosis. In addition, the statement supports the enrollee has not used a parathyroid analog for more than 24 months during the enrollees lifetime. Therefore, the prior authorization requirements have been met.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 a request for coverage of Tremfya 100 milligram per milliliter prefilled subcutaneous injection syringe. 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 Tremfya has been prescribed for the treatment of mixed connective tissue disease, osteoporosis, and arthritis. 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 conditions. Therefore, the drug is being prescribed for non-medically accepted indications 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: Favorable

At issue is a request for coverage of Forteo 620 microgram per 2.48 milliliter subcutaneous injection pen, 1 pen per 28 days. 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. The submitted medical records and prescriber statement indicate that Forteo has been prescribed for age-related osteoporosis in a male enrollee, which is a medically accepted indication outlined in the Medicare approved compendia. The prior authorization requirements for coverage of Forteo are that the drug is being used for a medically accepted indication and that the enrollee is at high risk for osteoporotic fracture. The medical records support the enrollee is at high risk for osteoporotic fracture, as evidenced by a history of fractures and low bone mass density scores. Therefore, the medical records validate that the plans prior authorization requirements have been met. Additionally, the plans quantity limit for the drug is 2.48 milliliters per 28 days, which is what is being requested. Therefore, coverage for the drug can be allowed. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.