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

At issue is Livalo 4 milligram tablets prescribed for hypercholesterolemia. 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 Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tymlos Pen Injector 80 micrograms prescribed for osteoporosis. 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 indicate the reasons why the enrollee could not take any of the alternative drugs on the plans formulary to treat the same 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 Diclofenac Sodium 1% External Gel to treat left shoulder pain. 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.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug because the diagnosis is not a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 150 microgram tablets prescribed daily for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. 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.Synthroid 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

You requested Armodafinil 250 milligram tablets prescribed daily for multiple sclerosis. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. 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. The submitted documentation indicates your doctor prescribed Armodafinil for multiple sclerosis. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not 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

At issue is a tiering exception request for Lyrica CR 165 milligrams 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.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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Levalbuterol 0.63 milligram/3 milliliter nebulizer solution prescribed for asthma. The Part D plan denied your request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D. We received a reconsideration request.We received a 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 Levalbuterol is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Levalbuterol. Please consider submitting this request to Medicare Part B. 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: Favorable

At issue is Praluent 150 milligram subcutaneous injections every 14 days. The Part D plan denied coverage because the documentation did not show a recent assessment of low-density lipoprotein cholesterolWe received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. Medical records and a prescriber statement were requested during this review and received. We reviewed all documentation submitted.The plans requirements for continued coverage of Praluent include documentation of recent assessment of recent low-density lipoprotein cholesterol level with decrease and continued treatment with maximally tolerated dose of a statin (if applicable). The prescriber statement and medical records submitted during this review support that the enrollee has been on Praluent injections since October 28, 2019, for the management of primary hyperlipidemia and atherosclerotic cardiovascular disease with a history of myocardial infarction and multiple stent placements. The records show that the enrollees baseline low-density lipoprotein cholesterol level on October 28, 2019, prior to starting Praluent therapy, was 170 milligrams per deciliter. The records support that the enrollee is statin intolerant having tried Atorvastatin and Rosuvastatin with both medications causing myalgias and severe cramping.The submitted laboratory results show that the enrollees low-density lipoprotein cholesterol level on September 1, 2020, was 72 milligrams per deciliter and that the enrollees most recent low-density lipoprotein cholesterol level obtained on January 8, 2021, has decreased to 54 milligrams per deciliter.Therefore, the newly submitted documentation confirms that the enrollees most recent low-density lipoprotein cholesterol level has deceased. Furthermore, the records support that the enrollee is statin intolerant and the second requirement for continued coverage of Praluent is not applicable to this enrollee. Therefore, the plans authorization requirements for continued therapy have been satisfied.A physician reviewed your appeal and determined that the plan is required to the Praluent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is the Fentanyl 25 microgram transdermal patch prescribed daily for chronic pain due to degeneration of the cervical intervertebral disc. The Part D plan denied coverage because 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. Your medical records show you were prescribed Fentanyl for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has been met. 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 Fentanyl patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 0.25 milligram dose pen prescribed once a week for type II diabetes. 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. Ozempic 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 Oxervate 0.002% Eye Drops prescribed for neurotrophic keratoconjunctivitis. 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 levelOxervate Eye Drops is a brand drug on Tier 4 of the plans formulary. Your doctor did not address why the all alternative medications would not work for you. All brand drugs on lower tiers have not been tried. 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 Myrbetriq ER 25 milligrams tablets to treat overactive bladder. 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. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows Myrbetriq ER 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 for the enrollees 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 a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 250 milligram tablets prescribed daily for orthostatic hypotension. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. 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. The submitted documentation indicates your doctor prescribed Armodafinil for orthostatic hypotension. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not 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 Cresemba 186 milligram oral capsule prescribed daily for pseudallesheria boydii. The Part D plan denied your request because the requested drug was not prescribed for a medically accepted indication. 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. The prescriber submitted a supporting statement and medical records that show Cresemba was prescribed to treat your pseudallesheria boydii. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Myrbetriq ER 50 milligram tablets prescribed for retention of urine, unspecified. The Part D plan denied your request for a tiering exception because Myrbetriq ER is a brand name Tier 4 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 Myrbetriq ER is a brand name Tier 4 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 coverage for Benztropine Mesylate 1 milligram capsules prescribed for other extrapyramidal disease, not medication induced. 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 Benztropine Mesylate for other extrapyramidal disease, not medication induced. In review of the Medicare approved compendium, other extrapyramidal disease, not medication induced is not a medically accepted indication for Benztropine Mesylate. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Benztropine Mesylate at issue.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Metopirone 250 milligram capsule as a diagnostic drug for testing the hypothalamic pituitary adrenocorticotropic hormone function in an enrollee with an abnormality of the pituitary gland and a history of empty sella.   The Part D plan denied the request because the manufacturer of the drug at issue did not participate in the Medicare Gap Discount Program. We received an expedited reconsideration 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 record shows the manufacturer of the drug at issue, HRA Pharma, does participate in the Medicare Gap Discount Program. Payment can be allowed for a drug whose manufacturer does participate in the Medicare Gap Discount Program.Metopirone 250 milligram capsule is not on the plans formulary.  There are no formulary alternatives to treat the same condition. 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: Favorable

At issue is Voriconazole 200 milligram tablet prescribed for prophylaxis of invasive aspergillosis for an enrollee on chemotherapy. 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 records show you prescribed Voriconazole as a prophylaxis to invasive aspergillosis for an enrollee on chemotherapy. The Medicare approved compendia do support the use of this drug for this condition.  The following citation in DrugDex, a Medicare approved compendium, supports the use of the requested drug for the enrollees condition:Voriconazole is suggested as alternative therapy to primary prophylaxis with posaconazole against invasive aspergillosis in high-risk patients (eg, those with prolonged neutropenia or immunosuppression); secondary prophylaxis is suggested in patients successfully treated for invasive pulmonary aspergillosis who require further immunosuppression [5].[5]  Patterson TF, Thompson GR, Denning DW, et al: Practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 63(4):e1-e60.The plan requires the drug be administered orally or intravenously before they will cover the requested drug. The documentation provided does show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Voriconazole 200 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Synthroid prescribed as directed to treat hypothyroidism. 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.Synthroid is a brand drug on Tier 4 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

At issue is Tresiba Flextouch 200 units/milliliter injection pent prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand biologics on a lower cost-sharing tier. 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.Tresiba Flextouch is a brand biologic on Tier 3 of the plans formulary. There are no brand biologics of the same type on the lower cost sharing tiers. Therefore, this biologic 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 Oxetellar XR 300 milligram tablets prescribed for partial symptomatic epilepsy with complex partial seizures. 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 Oxetellar XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide EC 3 milligram tablet to treat ulcerative colitis and noninfectious gastroenteritis. 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 Colistimethate Sodium (colistin base activity) for solution 150 milligrams to treat chronic respiratory failure. The Part D plan denied the request stating that the plan does not allow coverage of this medication when administered via nebulizer. 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.Although the drug can be administered via inhalation, your doctor states the drug is being prescribed to treat chronic respiratory failure. As such, 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.