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

You requested Oxandrolone 10 milligram tablets prescribed for lipodermatosclerosis. 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. The submitted documentation indicates your doctor prescribed Oxandrolone for lipodermatosclerosis. However, 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 coverage for Hetlioz 20 milligram capsules prescribed for the management of circadian rhythm sleep disorder free run type, non-24-hour sleep-wake disorder. 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. The documentation does not satisfy the plans coverage criteria. The prescriber has addressed the prior authorization criteria on the submitted prior authorization/order form; however, the responses do not satisfy all of the plans requirements for coverage of this medication. 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 tiering exception request for Xyosted Solution 100 milligrams per 0.5 milliliter to treat the enrollees condition. 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.Xyosted is a brand drug on Tier 4 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jadenu 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 documentation on hand includes a physician supporting statement. 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 Solifenacin Succinate 5 milligram tablets prescribed daily for the enrollees condition. 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.Solifenacin Succinate is a non-formulary brand drug. Non-formulary drugs are 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 Norditropin Flexpro Pen Injector 15 milligram/1.5 milliliters prescribed for adult hormonal failure. 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 regulations and Medicare approved compendia. The plan requires prior authorization requirements which includes federal food and drug approved uses only. The drug is not approved by the food and drug administration for the diagnosis submitted. The prior authorization requirements have not been met. A physician reviewed your appeal and determined that the plan is not required to cover Norditropin Flexpro Pen Injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Auryxia 1 gram 210 milligram tablet to treat iron deficiency anemia in enrollee with chronic kidney disease not on dialysis. 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.Drugs prescribed for use as vitamins and minerals are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nubequ 300 milligram tablets prescribe to treat metastatic prostate cancer, castrate resistant Stage IV. 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. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia does not support the use of the drug for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Nubequ.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate 2.5 milligram per 3 milliliter via nebulizer prescribed for asthma. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read all documentation submitted. This includes any information submitted at the reconsideration level.According to Medicare rules, the requested drug is eligible for coverage under the Part B durable medical equipment benefit. 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 Albuterol Sulfate. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica 200 milligram capsule three times daily to treat neuropathic 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 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 Revlimid 5 milligram capsule to treat myelodysplastic syndrome. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read all documentation submitted. This includes any information submitted at the reconsideration level.The documentation provided addressed the plans coverage criteria and those criteria were not satisfied. 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 tiering exception request for Crestor 10 milligram tablets prescribed for the enrollees condition. 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.Crestor 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 your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 20 microgram pen injector to treat osteoporosis, postmenopausal. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The documentation 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 records. A physician reviewed your appeal and determined that the plan is not required to cover Forteo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% Ointment prescribed to treat hemorroids. 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.The prescriber originally asked for this drug to treat the diagnosis of post-herpetic polyneuropathy. Upon reconsideration, the prescriber indicates the drug is being requested for hemorrhoids. However, the medical records submitted do not support the diagnosis reported. There is no supporting evidence the drug requested is prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% Ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxymorphone Hydrochloride Extended Release 40 milligram tablets prescribed every 8 hours and for an amount of 90 tablets per 30 days to treat 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 also researched Medicare regulations and Medicare approved compendia. The plan requires prior authorization requirements be met before covering this drug. The prior authorization requirements have not been met. A physician reviewed your appeal and determined that the plan is not required to cover Oxymorphone Hydrochloride Extended Release tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mavyret prescribe for the diagnosis of renal transplant pending, unknown Hepatitis C Virus (HCV) status. 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. We also researched Medicare regulations and Medicare approved compendia. The prescriber indicates that the enrollee has never been treated for chronic HCV and is presumed to have spontaneously cleared infection. Considering transplant from HCV positive donor. Medicare approved compendia does not support the use of the drug for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Mavyret.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Benztropine Mesylate 2 milligram tablets prescribed for schizophrenia, dystonia, and akathisia. 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 originally prescribed Benztropine Mesylate for bipolar disorder, and meralgia paresthetica. The medical records submitted added that the drug was prescribed for schizophrenia, dystonia, and akathisia. There is no further supporting elaboration on these diagnoses. The Medicare approved compendia do not support the use of this drug, as prescribed, 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 Lynparza 100 milligram tablets prescribed for metastatic squamous cell carcinoma of the right upper lung. 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 Lynparza for metastatic squamous cell carcinoma of the right upper lung. The Medicare approved compendia do not support the use of this drug for your condition. There are no Medicare approved journal articles submitted to support the use of the drug at issue 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 a tiering exception for Humira 40 milligram per 0.4 milliliter prefilled syringe kit prescribed for the treatment of rheumatoid arthritis. 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. Humira is listed on the plans formulary as Tier 5, which is the tier for specialty drugs. The plan does not grant tiering exceptions for specialty drugs. Therefore, this drug is not eligible for coverage at a lower-cost tier. A physician reviewed your 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 Brilinta 90 milligram tablets prescribed two times a day. 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. This drug is being provided by the plan at the cost sharing level of Tier 4. There are no brand name drugs in the lower cost-sharing tiers to treat your condition. 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 Prevymis 480 milligram tablets prescribed for heart transplant status. The Part D plan denied the request for a formulary 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. 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 Dimethyl Fumarate 240 DR capsules prescribed for multiple sclerosis. 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 Dimethyl Fumarate.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a tiering exception for Oxycontin ER 40 milligram tablets prescribed for chronic pain syndrome. 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.For a tiering exception to be granted, the documentation must support that the alternative drugs of the same type on the lower tiers of the plans formulary to treat the enrollees condition have been tried and failed, or are contraindicated. Oxycontin ER is a brand drug on Tier 3 of the plans formulary. The only alternative brand drug of the same type on a lower tier included in the plans formulary is Xtampza ER, which is on Tier 2 of the plans formulary.The prescriber statement and medical records submitted at reconsideration support that the enrollee switched from Oxycontin ER to Xtampza ER for approximately two months and did not achieve adequate pain control with the Xtampza ER during this trial period. Therefore, the documentation supports that the only alternative brand drug of the same type on a lower tier included in the plans formulary was tried and failed, and a tiering exception can be granted. A physician reviewed your appeal and determined that the plan is required to cover the Oxycontin ER at the Tier 2 level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Guanfacine Hydrochloride 2 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 indicates that Guanfacine Hydrochloride has been prescribed for the treatment of attention deficit hyperactivity disorder.  However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the noted condition in this age population. 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 your appeal and determined that the plan is not required to cover Guanfacine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Rytary 36.25-145 milligram extended release capsules prescribed for Parkinsons 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 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. Rytary is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the enrollees condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Rytary extended release capsules at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Desvenlafaxine Succinate Extended Release 100 milligram tablets prescribe twice a day for bipolar disorder and post-traumatic stress disorder, chronic.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia does not support the use of the drug for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Desvenlafaxine Succinate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 5 milligram capsules prescribed for failure to thrive and to promote appetite post transplant. 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.We determined that the plan is not required to cover Dronabinol because it was prescribed for weight gain. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira 40 milligram/0.4 milliliter pen injection kit prescribed for the enrollees condition. 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.Humira is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier are 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

At issue is Ibrance 125 milligram tablet to treat male breast cancer. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read all documentation submitted. This includes any information submitted at the reconsideration level.The documentation provided addressed the plans coverage criteria and those criteria were not satisfied. Scientific articles in Medicare approved journals were not submitted to support the use of Ibrance for this condition. Additionally, Medicare approved compendia do not support the use of Ibance for this condition. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.