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

You requested Erleada 60 milligram tablets prescribed as directed for metastatic prostate cancer. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The prescriber statement shows the physician prescribed Erleada to treat metastatic prostate cancer. The plan requested medical records from the prescriber to establish medical necessity. However, no medical records have been submitted for review. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, 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 Erleada.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 20 milligram tablets for treatment of the enrollees condition. The Part D plan denied your request for a tiering exception.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.Xarelto 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.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 Entresto (Sacubitril-Valsartan) 49-51 milligram tablets for treatment of the enrollees condition. The Part D plan denied your request for a tiering exception.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.Entresto 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.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

You requested a tiering exception for Januvia 100 milligram tablets prescribed for diabetes. The Part D plan denied your request for a tiering exception because Januvia is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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 plan shows Januvia is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eliquis 2.5 milligram tablets prescribed for paroxysmal atrial fibrillation. The Part D plan denied your 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 Eliquis for paroxysmal atrial fibrillation in an enrollee with a biomechanical valve replacement. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that the drug was 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 Procrit 1000 milliliter vial prescribed for end stage renal disease. 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 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 record shows the physician ordered Procrit for low hemoglobin associated with renal transplant. According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. We determined that the plan is not required to cover the Procrit. Drugs which are eligible for Part B coverage are excluded from Part D coverage.We determined that the plan is not required to cover the Procrit vial.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Myrbetriq ER 50 milligram tablets prescribed daily for urge incontinence. 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 also researched Medicare systems and reviewed the enrollment data available. Myrbetriq ER 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 of the plans formulary. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20 milligrams to treat pulmonary artery hypertension. 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 regulations and Medicare approved compendia.The record shows you were prescribed Sildenafil for pulmonary arterial hypertension. Documented heart catheterization values are not consistent with the diagnosis of pulmonary artery hypertension.  Medicare approved compendium,do not support the use of the requested drug for your condition. Therefore, it is not considered to be a medically accepted indication. 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 coverage for Prevalite 4 gram powder prescribed daily for chronic diarrhea, unspecified. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Prevalite for chronic diarrhea, unspecified. In review of the Medicare approved compendia, chronic diarrhea, unspecified is not a medically accepted indication for Prevalite. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Prevalite at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulicity 1.5 milligram/0.5 milliliter pen. 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.Trulicity is a biological drug on Tier 3 of the plans formulary. There are no biological 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 a tiering exception. There are no lower tiered biological drugs of the same type to treat the enrollee's condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathioprine 50 milligram tablet prescribed to treat cardiac sarcoidosis and dilated cardiomyopathy with a biventricular implantable cardioverter defibrillator in place. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted conditions. 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. A physician reviewed your appeal and determined that the plan is not required to cover Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Desvenlafaxine Succinate ER 100 milligram 24-hour extended release 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 documentation indicates that Desvenlafaxine Succinate ER has been prescribed for bipolar I disorder, current episode depressed, moderate; posttraumatic stress disorder, chronic; and obsessive-compulsive disorder, mixed obsessional thoughts and acts. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for 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 your appeal and determined that the plan is not required to cover the Desvenlafaxine Succinate ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ajovy 225 milligrams per 15 milliliter for migraine prophylaxis. 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 asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.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. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azopt 1 percent eye drop suspension prescribed as directed for primary open angle glaucoma. 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 also researched Medicare systems and reviewed the enrollment data available.  The requested drug is being provided by your plan under a formulary exception. Azopt 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 your appeal and determined that non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Balversa 4 milligram tablets prescribed as directed to treat glioblastoma. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee has glioblastoma. Molecular testing showed FGFR3 amplification and FGFR3-TACC3 fusion. Therefore, the physician prescribed Balversa, which is an FGFR kinase inhibitor. It is noted the provider submitted medical literature. However, the Medicare approved compendia do not support the use of the requested drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Balversa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Botox 200 unit solution prescribed for chronic migraine. The Part D plan denied the 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 records submitted indicate the drug at issue will be administered by your doctor in the office. This is eligible for coverage under Part B. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Botox.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Tramadol Hydrochloride 50 milligram tablets prescribed for chronic lower back pain. The Part D plan denied the request for coverage because the prescriber did not provide a statement verifying that the medication would be necessary for more than 7 days to treat the enrollees condition.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 medical records and prescriber statement submitted support that the Tramadol Hydrochloride was prescribed for severe, chronic lower back pain. However, the prescriber has not included a statement verifying that the medication would be necessary for more than seven days. A physician reviewed the appeal and determined that the plan is not required to cover the Tramadol Hydrochloride.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Deferasirox 360 milligram tablets prescribed for hemosiderosis. The Part D plan denied coverage.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 enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee was prescribed Deferasirox due to hemosiderosis from repeated red blood cell transfusions. The enrollee has myelodysplastic disease and iron overload from repeated blood transfusions.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Evenity to treat the enrollees condition. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligrams/milliliter injection prescribed for hyperlipidemia with atherosclerotic cardiovascular disease. The Part D plan denied your 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 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 Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Edarbyclor 40-12.5 milligram tablets prescribed for primary hypertension. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Edarbyclor is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, 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

You requested Modafinil 100 milligram tablets prescribed as needed for other fatigue, sleep disorder unspecified, and somnolence. 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 also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Modafinil to treat your other fatigue, fatigue from multiple sclerosis, sleep disorder unspecified, and somnolence. 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 the Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Edarbi 80 milligram tablets prescribed daily for hypertension. The Part D plan denied your 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 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 Edarbi.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% Patch prescribed daily for illness unspecified. The Part D plan denied your request because 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 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 did not receive the documentation requested.At initial determination and redetermination the diagnosis of illness unspecified was given. At reconsideration, the diagnosis of pain due to diabetic neuropathy was given. No medical records were provided by the prescriber to support the change in diagnosis. Therefore, it cannot be determined whether the requested drug was prescribed for a medically accepted indication. 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.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Januvia 100 milligram tablets prescribed to treat the enrollees condition. 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 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.Januvia is a brand drug on Tier 3 of the plans formulary. There are no brand names of the same type on the lower cost-sharing levels. 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 coverage for Osphena 60 milligram tablets. 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 submitted to the plan indicates that Osphena has been prescribed to treat postmenopausal atrophic vaginitis. However, the Medicare approved compendia do not contain any citations to support the use of Osphena for the treatment of postmenopausal atrophic vaginitis.At reconsideration, an unsigned note has been submitted that states the Osphena is being prescribed for dyspareunia due to vaginal atrophy. However, it is not possible to determine if the prescriber wrote the note, as there are 5 physicians names listed on the letterhead of the document and, as noted before, the document has not been signed. Furthermore, no medical records have been submitted to validate the change in diagnosis. Therefore, there is insufficient documentation to determine if the Osphena is being prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the plan is not required to cover the Osphena.