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

At issue is Trelegy Ellipta 100 microgram-62.5 microgram-25 microgram. 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. 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 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 Myfortic 180 milligram delayed release tablet prescribed for an enrollee status post a kidney transplant. 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 enrollee did not have the transplant while enrolled in Medicare and the drug is Part D eligible. However, the drug is not on the plans formulary. We requested additional information from the prescriber. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the prescriber does not indicate why the other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Myfortic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lumakras 120 milligram tablet prescribed for non-small cell lung cancer. 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 indicates Lumakras is prescribed to treat non-small cell lung cancer and is not a candidate for systemic therapy as the enrollee has peripheral neuropathy and recent falls. Lumakras was requested as front line therapy. However, Medicare approved compendia and the Food and Drug Administration criteria state Lumakras is indicated for the treatment of adult patients with KRAS G12C-mutated locally advanced or metastatic non-small cell lung cancer, as determined by a Food and Drug Administration approved test, who have received at least one prior systemic therapy and the enrollee has not had any systemic therapy thus far (only localized therapy with radiation and surgery). There were no articles provided to show that Lumakras can be efficacious in the first-line setting of metastatic disease. A physician reviewed your appeal and determined that the plan is not required to cover Lumakras.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Esbriet 267 milligram capsule prescribed for pulmonary fibrosis, unspecified and chronic fibrosing interstitial lung disease with a progressive phenotype. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber indicates Esbriet 257 milligram capsules are prescribed to treat interstitial lung disease. However, 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 Esbriet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick Auto Injector 140 milligram/milliliter prescribed for hyperlipidemia, unspecified. 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the prescriber does not indicate why the other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick Auto Injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fentanyl Patch 37.5 microgram/hour prescribed for chronic pain. 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. Fentanyl Patch 37.5 microgram/hour is a generic drug on Tier 4 of the plans formulary. The documentation does not support that all drugs available on lower tiers to treat your condition have been tried or deemed contraindicated. 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 a formulary exception request for Cosentyx 150 milligrams per milliliter (300 milligrams dose) solution pre-filled syringe prescribed to treat the enrollee with psoriasis vulgaris. The Part D plan denied the appeal 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 shows the doctor prescribed Cosentyx 150 milligrams per milliliter (300 milligrams dose) solution pre-filled syringe to treat psoriasis vulgaris. The use of the requested drug to treat the provided diagnosis is an off-label use. The Part D plan denied the appeal request stating that the plans formulary exception requirements were not met. 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 enrollees 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 Cosentyx 150 milligrams per milliliter (300 milligrams dose) solution pre-filled syringe.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gammaplex 5% intravenous solution prescribed for seropositive autoimmune limbic encephalitis. 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 submitted documentation indicates the prescriber ordered the requested drug for the enrollees noted condition. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise 600-milligram tablet to treat drug induced polyneuropathy and postherpetic polyneuropathy. The Part D plan denied the request. The requested drug is not on the plans formulary. 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.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. Furthermore, since the drug is not approved, a tiering exception cannot be offered. 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 Myrbetriq Extended Release 25 milligram tablet prescribed for urinary urge incontinence. 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. Myrbetriq Extended Release 25 milligram 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 Phospha 250 Neutral 155 milligram-852 milligram-130 milligram tablet prescribed for hypophosphatemia. 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.Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Phospha 250 Neutral 155 milligram-852 milligram-130 milligram tablet is not a Food and Drug Administration approved drug. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to cover Phospha 250 Neutral 155 milligram-852 milligram-130 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tramadol Hydrochloride Extended Release 100 milligram tablet prescribed for chronic shoulder 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 requested additional information from the prescriber but the documentation does not satisfy the requirements. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The enrollee has not satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Tramadol Hydrochloride Extended Release tablets. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Nucynta 100 milligram tablets prescribed to treat the enrollee with leg pain. The Part D plan denied the appeal 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.Nucynta 100 milligram tablets is not included in the plans formulary (list of covered drugs). The prescriber indicates that a couple of plans alternative formulary drugs were tried and failed or could cause harm. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the records do not support why all other drugs on the plans formulary would not work for the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Nucynta 100 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 4 milligram tablets prescribed for chemotherapy-induced nausea and vomiting. 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. Medicare rules state that for prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must be for treatment of a condition that is completely unrelated to the terminal condition(s) or related conditions for which hospice coverage is being provided. The record shows the drug at issue is being used for treatment of a condition that is related to hospice. However, your drug appears to be eligible for Part A coverage. We determined that the Part D plan is not required to cover the drug at issue. Please submit your request to Medicare Part A. 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 Guardian Glucose Monitoring Sensor. 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. Guardian Glucose Monitoring Sensor is a device used to monitor glucose levels. Medical devices are not eligible for Part D coverage. However, this drug may be covered under Medicare Part B benefits. We determined that the plan is not required to cover Guardian Glucose Monitoring Sensor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Nuedexta 20/10 milligram capsules prescribed for pseudobulbar affect. The Part D plan denied coverage.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 records submitted at the reconsideration level. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee satisfies the plan's prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.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 Cyclobenzaprine Hydrochloride 10-milligram tablet to treat pain associated with muscle spasm of back. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. This drug is considered a high-risk medication in older enrollees. 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed, with support of medical records, the issues regarding this high-risk medication, and why alternative safer medications, in the plan's formulary, could not be used. 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 Banatrol Plus powder packet prescribed for colitis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Banatrol Plus because it is an over-the-counter medication. Nonprescription or over-the-counter drugs are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Phenazopyridine Hydrochloride 100 milligram tablets. 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 drug at issue is not Food and Drug Administration approved. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Armodafinil 200-milligram tablet to treat major depression and multiple sclerosis related fatigue. 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 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 Sildenafil Citrate 100 milligram tablets prescribed for erectile dysfunction. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Sildenafil Citrate because it was prescribed for erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Lynparza 100 milligram tablet prescribed for advanced lung adenocarcinoma. 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 indicates Lynparza is prescribed for lower left lobe adenocarcinoma of the lung that is advanced with pleural effusion. The prescriber indicates the enrollee was started on Keytruda but molecular profiling also showed ATM mutation and Lynparza is requested. However, per the Food and Drug Administration and Medicare approved compendia, Lynparza is not indicated for non-small cell lung cancer that has HRR mutations (including ATM and BRCA). The prescriber submitted an article to support the use of Lynparza in the enrollee but it was not from a Medicare approved journal and was not done in patients but done in BRCA depleted cell lines. Therefore, we cannot accept this study. A molecular profiling study (Guardant 360) listed Lynparza as a Food and Drug Administration approved therapy for ATM mutation. However, it is important to note that this is not indicated in lung cancer per Food and Drug Administration and Medicare approved compendia. A physician reviewed your appeal and determined that the plan is not required to cover Lynparza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fanapt 4 milligram tablet prescribed for bipolar disorder, unspecified and intermittent explosive 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 prescriber indicates Fanapt is prescribed to treat bipolar disorder, unspecified and intermittent explosive disorder. However, 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 Fanapt.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Nurtec 75 milligram oral disintegrating tablets prescribed to treat the enrollee with chronic migraines. The Part D plan denied the appeal 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. We also researched Medicare systems and reviewed the enrollment data available.Nurtec 75 milligram oral disintegrating tablets is not included in the plans formulary (list of covered drugs). In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why all other drugs on the plans formulary would not work for the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Nurtec 75 milligram oral disintegrating tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tizanidine Hydrochloride 4-milligram tablet to treat low back pain and postlaminectomy syndrome, unspecified. 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 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.