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

At issue Xiidra 5% solution droperette to treat dry eye syndrome and bilateral corneal dystrophies. The Part D plan denied the request. We received a standard reconsideration request. We performed and 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 requires a diagnosis of keratoconjunctivitis based on objective test such as Schirmers: test results-10 milimeters or less of moisture after 5 minutes or non-invasive tear breakup time, osmolarity or ocular surface staining.  The documentation does not include an objective test and results. Therefore, the prior authorization requirements were not met.   A physician reviewed your appeal and determined that the plan is not required to cover Xiidra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Opium oral tincture 10 milligrams/milliliter prescribed as directed. The Part D plan denied your 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 under a formulary exception. It 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 the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xospata 40 milligram tablets prescribed as directed for high risk myelodysplastic syndrome. 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 letter of medical necessity states the enrollee has high risk myelodysplastic syndrome. No medical records were provided by the prescriber to support the enrollees diagnosis, medical history, and prior treatments. 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 Xospata.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tetrabenazine 12.5 milligram tablets to treat the enrollees condition. The Part D plan denied the request for a cost-sharing tier 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.Tetrabenazine is a generic drug on Tier 5 (specialty drug) of the plans formulary. Drugs on the plans specialty tier are not eligible for a tiering exception. Therefore, this drug is not eligible for a cost-sharing tier exception.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Cinacalcet Hydrochloride 30 milligram tablets prescribed to treat hypercalcemia in a renal transplant recipient with persistent hyperparathyroidism. The Part D plan denied your request stating that coverage is not provided under Part D for end-stage renal disease patients. 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 use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia contain a positive citation to support the use of the requested drug, as prescribed, for the treatment of this condition. Micromedex states Cinacalcet treatment significantly decreased the mean corrected total serum calcium to less than 10.2 milligram/deciliter in 78.9% of patients compared with 3.5% with placebo in a 26 week, randomized study of renal transplant recipients with hypercalcemia and persistent hyperparathyroidism (N=114). An extensive office note of March 21, 2012 details history and entries dated October 23, 2019, and May 26, 2020, confirm hypercalcemia, controlled with Cinacalcet, and details otherwise normal renal function post transplant, no longer on dialysis. Therefore, the requested drug is being used for a medically accepted indication and is eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is required to cover Cinacalcet Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tizanidine hydrochloride 4 milligram tablets prescribed as directed for osteoarthritis of both knees and degenerative disc disease of the lumbar region. 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 Tizanidine hydrochloride for osteoarthritis of both knees and degenerative disc disease of the lumbar region. The physician states the enrollee has been using this medication since 2012. 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 Tizanidine hydrochloride.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Repatha Sureclick, 140 milligram auto-Injector prescribed to treat hyperlipidemia. 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 records submitted at the reconsideration level. The prescriber has submitted a statement and medical records indicating that the enrollee has myagias on statins and Ezetimibe. Therefore, the prior authorization requirements were met. A physician reviewed your appeal and determined that the plan is required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Letairis 10 milligrams prescribed as directed to treat pulmonary hypertension, unspecified. 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 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 this 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 Letairis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Emgality 120 milligram/milliliter pen prescribed to treat your condition. 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 did not receive the documentation requested.The plan requires prior authorization criteria be met before they will cover the requested biologic. The documentation provided does not show you have satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Emgality 120 milligram/milliliter pen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5 milligram tablet prescribed daily for benign prostatic hyperplasia. 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 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 medical records show you prescribed Tadalafil 5 milligram tablet to treat the enrollees nocturia secondary to benign prostatic hyperplasia. The Medicare approved compendia do support the use of this drug for this condition. The plan requires prior authorization criteria be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Tadalafil 5 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Farxiga 10 milligrams to treat diabetes mellitus.   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.Farxiga 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trelegy Ellipta 200-62.5-25 to treat asthma. 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.Trelegy Ellipta 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. Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% Ointment to treat polyneuropathy. 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 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 requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Atovaquone 750 milligrams/5 milliliters for prophylaxis of pneumocystis jiroveci pneumonia. 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.This drug is being provided by the plan at the cost-sharing level of the specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. 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: Favorable

At issue is the InPen NN MIS 150 milligrams prescribed as directed for type 1 diabetes. The Part D plan denied the request for 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 information submitted at the reconsideration level.We asked your prescriber to clarify your medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked to address the plans formulary alternatives. We received the documentation and included it in our review. Your medical records show you were prescribed InPen NN MIS to treat your type 1 diabetes. Your physician stated that due to a functional cognitive disorder that the Novolog flexpen and vial were tried and resulted in missed doses and incorrectly calculated doses, which put you at risk for severe hyperglycemia or hypoglycemia. The prescriber stated that this was a safety issue.  The provided medical records document a cognitive disorder. A physician reviewed your appeal and determined that the plan is required to cover the InPen NN MIS because all alternative drugs on the plans formulary have been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan Potassium 25 milligrams, ('take 3 tablets daily') to treat hypertension. The Part D plan auto forwarded the request to us.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 record shows you are prescribed Losartan Potassium. We asked your prescriber to send us your medical records, to address the requested quantity, a prescriber statement, and a list of other drugs tried and the results. We did not receive the requested documentation.The plan limits the amount of Losartan Potassium to plan to 60 tablets per 30-days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported.  Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 50 milligram capsules to treat polyneuropathy in an enrollee with a documented allergy to Pregabalin.  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 was asked why they are prescribing Pregabalin to a patient who has an allergy, contraindication or history of adverse effects with Pregabalin.  The prescriber was also asked to provide relevant medical records.  The prescriber sent a reply on March 9, 2021 but did not answer the question relating to Pregabalin.  The prescriber send medical records from date of service 2/4/2021 which documented a drug allergy to Pregabalin. 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 Lidocaine Patch to treat chronic pain and fibromyalgia. 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 use of the requested Lidocaine Patch 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 requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine HCL 8 milligram sublingual tablet prescribed for chronic pain syndrome. The Part D plan denied the request. We received an expedited reconsideration request. We performed and 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 documentation shows the doctor prescribed Buprenorphine HCL sublingual tablets for pain. However, the Medicare approved compendia do not support the use of this drug in sublingual form for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine HCL sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Linzess 145 microgram capsule prescribed as directed to treat irritable bowel syndrome with constipation. 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 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.Linzess 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vyvanse 40 milligram capsules prescribed as directed for major depressive 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 Vyvanse for treatment of, 'treatment resistant major depressive disorder.'  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 Vyvanse.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed for the treatment of acute muscle spasm. The Part D plan denied coverage because the prior authorization requirements were not met. 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 records submitted at the reconsideration level. A prescriber statement was requested from the prescribing physician during this review, but not received.The documentation does not satisfy the plans coverage criteria. The prescribing physician has addressed the prior authorization criteria; 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 Dexamethasone 0.5 milligrams per 5 milliliters elixir, administered via rinse and spit to prevent the recurrence of a benign neoplasm of the tongue.  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.  Relevant medical records were requested but not provided. 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 Dronabinol 2.5 milligram capsule to treat weight loss caused by unspecified heart failure. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.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 Forteo Pen Injector 20 micrograms prescribed to treat osteopenia with FRAX score of 27% for osteoporotic fractures. The Part D plan denied your request. We received an auto-forward 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 Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees condition. The drug is not approved by the Food and Drug Administration to treat the diagnosis submitted. 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 Forteo.