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

At issue is Myrbetriq 50 milligram extended-release 24-hour tablets. The Part D plan denied the appeal 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 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: Favorable

At issue is Sirturo for nontuberculosis mycobacterium 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.The submitted documentation indicates the prescriber ordered Sirturo for nontuberculosis mycobacterium infection. The Medicare approved compendium contains a citation to support this drug has an orphan drug status for the prescribed diagnosis. The plan has prior authorization criteria for the prescribed drug; however, the medical records indicate multiple drug resistant disease and side effects associated with intravenous amikacin and limited choices of drugs for treatment. An exception to the plan's prior authorization criteria is required for adequate treatment of the enrollee's disease. The quantity limit for four weeks of therapy at the initiation of therapy is 84 one hundred milligram tablets.A physician reviewed the appeal and determined that the plan is required to cover the requested drug as a prior authorization exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Creon delayed-release 36,000 unit capsules. The Part D plan denied the appeal 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.Creon 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 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 Danazol 50 milligram capsules. The Part D plan denied the appeal 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.Danazol is a generic drug on Tier 4 of the plans formulary. There are no generic drugs of the same type for the enrollees condition 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 Febuxostat 40 milligram tablets prescribed to treat gout. 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 file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber indicates that a couple of plans alternative formulary drugs were tried and failed or could cause harm. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the records do not support why all other drugs on the plans formulary would not work for the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Febuxostat 40 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Actemra 162 milligram/0.9 milliliter injection prescribed for lung disease with systemic sclerosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. However, we did not receive the documentation.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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Actemra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tramadol Hydrochloride 200 milligram extended release tablets prescribed for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. However, we did not receive the documentation.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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Tramadol Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Epogen 10,000 units per milliliter for subcutaneous injection prescribed for anemia associated with chronic kidney disease. 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. Epogen 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 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. During this review, a request was submitted to the prescriber to address the alternative medications included in the plans formulary. The prescriber did not respond to the request. 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 Budesonide 0.5 milligram/2 milliliter suspension prescribed via nasal irrigation for chronic sinusitis and nasal polyposis. 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 Budesonide via nasal irrigation for chronic sinusitis and nasal polyposis. 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 prior authorization request for Zolpidem Tartrate 10 milligram tablets prescribed daily for insomnia. The Part D plan denied coverage.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 records submitted at the reconsideration level. The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.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 request for Nucynta 75 milligram tablet prescribed 50 tablets every 12 days for chronic pain. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation indicates the doctor prescribed Nucynta 75 milligram tablet to treat the enrollees chronic pain. Although a letter is submitted indicating that Hydromorphone Hydrochloride has been discontinued,medical records were not submitted to support it was discontinued. The quantity requested does not meet the plan's criteria. Therefore, the plan is not required to cover Nucynta 75 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is for Ztlido 1.8% patch prescribed for other post herpetic nervous system involvement. 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. We asked your prescriber to send us information regarding th enrollee's condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. However, we did not receive the documentation. 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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Ztlido.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone-Acetaminophen 10-325 milligram tablet prescribed for chronic pain. 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. We requested additional information from the prescriber to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, the dose is appropriate, if there is their concurrent use of an opioid agent with a benzodiazepine that is medically necessary, and that the prescriber has checked the states Prescription Drug Monitoring Program. We did not receive information that could answer these medical necessity issues.  The requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Oxycodone-Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a quantity limit exception for Austedo 12 milligram tablets. 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 documentation indicates the prescriber ordered Austedo for abnormal involuntary movements. The prescriber requested 180 tablets for a 90-day supply. The plan approved a 30-day supply. The drug at issue is a specialty drug and is only able to be dispensed as a 30-day supply. Therefore, a quantity limit exception cannot be granted and the amount approved by the plan is upheld.Therefore, the plan is not required to cover Austedo for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq extended-release 50 milligram tablets. The Part D plan denied the appeal 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 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 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 request for coverage of Erleada 60 milligram tablets prescribed for the treatment of metastatic castration-resistant prostate cancer. The Part D plan denied the request stating that the drug was being used for 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. The documentation does not include any peer-reviewed, clinically relevant medical literature from an approved journal to support the use of the requested drug for the treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Hetlioz 20 milligram capsules prescribed for non-24 hour sleep/wake disorder. The Part D plan denied coverage.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 levelThe documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.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 request for coverage of Mitomycin C  0.04% ophthalmic solution prescribed for malignant neoplasm of the left conjunctiva. 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligram/2 milliliter pen injector prescribed for lichen simplex chronicus and prurigo. 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 Dupixent for lichen simplex chronicus and prurigo. 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.A physician reviewed the appeal and determined that the plan is not required to cover the requested biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram/milliliter injection prescribed for coronary artery disease. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. However, we did not receive the documentation.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 your appeal and determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine-Prilocaine 2.5% -2.5% topical cream. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Lidocaine-Prilocaine cream has been prescribed for the treatment of foot pain due to the presence of gout. 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 Diflorasone Diacetate 0.05% ointment prescribed 120 grams per 30 days. 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 this medication was needed. We did not receive the documentation requested.The doctor prescribed Diflorasone Diacetate 0.05% ointment. There was no diagnosis or medical records provided by the prescriber to support a covered condition. It could not be determined whether the requested drug was being prescribed for a medically accepted indication.A physician reviewed the appeal and determined that the plan is not required to cover Diflorasone Diacetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lynparza 150 milligram tablets prescribed for the treatment of anaplastic oligodendroglioma with IDH1 mutation. 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 requested Lynparza to be used in combination with Temodar to treat the enrollees IDH1-mutated oligodendroglioma. However, 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. The documentation does not include any peer-reviewed, clinically relevant medical literature from an approved journal to support the use of the requested drug for the treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.