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

You requested Corlanor 5 milligram tablets prescribed twice daily for inappropriate sinus tachycardia. 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 physician prescribed Corlanor for the treatment of inappropriate sinus tachycardia. The physician states the enrollee also has coronary artery disease and a history of heart murmurs. However, the Medicare approved compendia do not 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 Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levalbuterol inhalation solution 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. 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 your conditions. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 Uptravi 200 milligram tablets prescribed for the enrollees pulmonary arterial hypertension. 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. The documentation supports the drug was prescribed for the enrollees diagnosis of pulmonary arterial hypertension. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eletriptan Hydrobromide 40 milligram tablets prescribed to treat migraines. The Part D plan denied the request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The records do not show why the enrollee cannot take other drugs on the plans formulary for their condition.A physician reviewed your appeal and determined that the plan is not required to cover a formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dexilant 60 milligram oral capsule prescribed twice daily. The Part D plan denied your request for a tiering 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. Dexilant 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 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 Methylphenidate 10 milligram tablets prescribed as directed for major depressive disorder and generalized anxiety disorder. 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 physician prescribed Methylphenidate for major depressive disorder and generalized anxiety disorder. However, the Medicare approved compendia do not support the use of this drug for the enrollees conditions. A physician reviewed your appeal and determined that the plan is not required to cover Methylphendiate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Emgality to treat cluster headaches. The Part D plan denied your request for a non-formulary exception. We received an expedited 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 records submitted at the reconsideration level. The prescriber has not indicated why all alternatives which are required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Voriconazole. 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 Voriconazole has been prescribed for the treatment of pulmonary cryptoccoccosis. 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 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 the Voriconazole.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vascepa 1 gram tablets to treat hypertriglyceridemia.  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 clarified the medical history in a statement. The prescriber stated that the requested medication will not be used as an adjunct to maximally tolerated statin therapy, unless there is a contraindication or intolerance to statin therapy.  Relevant medical records were requested. The medical records provided document that the enrollee has no known allergies.  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 Enbrel Sureclick Auto-Injector to treat rheumatoid arthritis. The Part D plan denied 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 records submitted at the reconsideration level.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.However, the documentation available does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical recordsA physician reviewed your appeal and determined that the plan is not required to cover Enbrel Sureclick Auto-Injector.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for non-formulary Methylphenidate Hydrochloride ER 20 milligram capsules. The Part D plan denied your request because the medication was being used for a non-medically accepted indication. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. Medical records were requested during this review and received. We reviewed all documentation submittedThe documentation supports that Methylphenidate Hydrochloride ER has been prescribed to treat the 73-year-old enrollees major depressive disorder. An off-label indication for Methylphenidate Hydrochloride included in one of the Medicare approved compendia is in the treatment of major depressive disorder (unipolar) in elderly patients.However, Methylphenidate Hydrochloride ER is not included in the plans formulary and the prescriber has not sufficiently explained why the all of the drugs that are included in the plan to treat the enrollees condition have been tried and failed or would likely not be as effective as the requested drug or would likely cause adverse reactions or other harm.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

Celecoxib 200 milligram capsules were requested for psoriatic arthritis. The Part D plan denied the request initially because it did not meet the criteria of a medically accepted indication. At redetermination the plan denied as off-formulary criteria not satisfied. 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.Celecoxib 200 milligram capsules twice daily was requested for psoriatic arthritis A citation in Micromedex, a Medicare approved compendium, supports the use of the requested drug for the condition indicated:  Psoriatic Arthritis: Clinical Practice Guidelines. Therefore, it is considered a medically accepted indication.The drug is not on the plans formulary.  The plans coverage criteria state that the prescriber must indicate 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. The prescriber has submitted medical records and a prescriber statement on March 6, 2021, that addresses all alternatives required by the plan. Therefore, an exception to the plans formulary coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed as directed for non-24 hour sleep/wake cycle. The Part D plan denied coverage. 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. The prescriber statement provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuvigil 250 milligram tablet prescribed daily for daytime fatigue associated with Parkinsons disease. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.The prescriber statement submitted indicates that Nuvigil 250 milligram tablet will be used to treat the enrollees narcolepsy. However, the medical records submitted make no mention of a diagnosis of narcolepsy. The medical records submitted indicate that Nuvigil is prescribed for daytime fatigue associated with Parkinsons disease. The Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Nuvigil 250 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid to treat hypothyroidism.  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 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.Non-FDA approved drugs are excluded from Medicare Part D coverage.  Per the Medicare approved compendia, This drug has not been found by the US FDA to be safe and effective, and the drug product labeling has not been approved by the FDA. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed as directed for non-24 hour sleep-wake cycle. The Part D plan denied coverage because the prior authorization criteria were not met. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We asked the prescriber to send us a supporting statement and medical records to show why Hetlioz is medically necessary. However, we did not receive the documentation.The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hetlioz 20 milligram capsules prescribed as directed. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.We asked the prescriber to send us a supporting statement and medical records to show why Hetlioz is medically necessary. However, we did not receive the documentation. The prescription shows Hetlioz was prescribed for non-24 hour sleep-wake cycle. No medical records were provided by the prescriber to support the enrollees diagnosis. 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 Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vemlidy 25 milligram tablets prescribed as directed. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The documentation shows the enrollee was prescribed Vemlidy for chronic viral hepatitis B infection. The documentation provided did not identify if the enrollee has compensated liver disease. 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 Vemlidy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica 100 milligram capsules to treat post-herpetic neuralgia. The Part D plan denied the request. The requested drug is not on the plans formulary. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The prescriber has not 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

At issue is a tiering exception request for Flecainide acetate 50 milligram tablet prescribed as directed to treat essential hypertension. The Part D plan denied the request. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Flecainide acetate 50 milligram tablet is a generic drug on Tier 3 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

Uceris 2 milligram rectal foam was requested for ulcerative colitis.  The Part D plan denied the request.  The requested drug is not on the plans formulary. We received an auto-forward request.We performed an independent and de novo review. To make our decision, we read your cae file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide 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. We did not receive this information. Therefore, an exception to the plans formulary coverage criteria is not medically necessary. 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 Latuda 20 milligram tablets prescribed for depression with bipolar. The Part D plan denied your request for a tier change request because Tetrabenazine is in the specialty tier of your list of covered 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. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Tetrabenazine is a brand name Tier 5 drug. Your plan does not allow you to receive drugs in this tier at a lower cost share.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Lumigan 0.01 percent prescribed daily for glaucoma. The Part D plan denied your request for a tiering exception because Tresiba 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. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Lumigan 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

At issue is Glatiramer Acetate 40 milligram/milliliter syringe prescribed for the enrollees relapsing form of multiple sclerosis. 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. The documentation supports the drug was prescribed for the enrollees diagnosis of relapsing form of multiple sclerosis. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Belsomra 10 milligram tablets prescribed for insomnia. 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 did not indicate all formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. 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 Belsomra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Xifaxan 550 milligram tablets prescribed for small intestinal bacterial overgrowth. 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 Xifaxan for small intestinal bacterial overgrowth. In review of the Medicare approved compendium, small intestinal bacterial overgrowth is not a medically accepted indication for Xifaxan. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Xifaxan at issue.