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

At issue is Auryxia 210 milligram tablets prescribed to take 2 tablets by mouth, three times daily, with meals to treat disorder of phosphorus metabolism and end-stage renal disease. 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.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.A physician reviewed your appeal and determined that the plan is not required to cover Auryxia 210 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Opsumit 10 milligram tablets prescribed for pulmonary arterial hypertension. 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 included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tier exception for drugs available on their Specialty Tier. Therefore, a tier exception cannot be considered.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 Trelegy Ellipta 100-62.5-25 micrograms per actuation prescribed daily for chronic obstructive pulmonary disease. The Part D plan did not make a decision.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.Trelegy Ellipta 100-62.5-25 micrograms per actuation 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 Xeljanz XR 5 milligram tablets prescribed for alopecia areata, unspecified. 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 documentation shows your doctor prescribed Xeljanz XR to treat your alopecia areata, unspecified. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz XR.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate 2.5 milligram/3 milliliter solution prescribed for asthma. 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 determined that the drug is eligible for Part B coverage. A nebulizer administers the drug. 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 Albuterol Sulfate solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Onetouch verio test strip prescribed for the diagnosis of diabetes. 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 determined that the plan is not required to Onetouch verio test strip because it is not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. 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

You requested Cyanocobalamin solution 1000 microgram/milliliter prescribed for unknown diagnosis. 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. According to Medicare rules, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Cyanocobalamin. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amphetamine/Dextroamphetamine 20 milligram capsule  prescribed for attention deficit disorder. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. 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. A physician reviewed your appeal and determined that the plan is not required to cover Amphetamine/Dextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram oral capsule for non-24 hour sleep wake cycle. 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 records submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The records show your doctor prescribed Hetlioz to treat non-24 hour sleep wake cycle. The Medicare approved compendia do support the use of this drug for your condition.However, the plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria. There were no medical records submitted for review.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Interferon alfa-2b 1,000,000 international units per milliliter compounded solution prescribed as directed for eye cancer. 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 asked your prescriber to send us information regarding this compounded medication. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The reimbursement request form shows that you believe your doctor prescribed Interferon alfa-2b compounded solution to treat your eye cancer. The documentation available for review does not include a list of ingredients for the compounded drug or medical records supporting your diagnosis. It could not be determined whether the requested compounded drug was prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to provide reimbursement for Interferon alfa-2b compounded solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% topical patch prescribed for pain associated with diabetic neuropathy. The Part D plan denied your request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The documentation shows your doctor prescribed Lidocaine 5% topical patch to treat your pain associated with diabetic neuropathy. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 3% gel to treat chronic pain syndrome, diabetic neuropathy, spondylosis of lumbar region, and right arm lymphedema and cellulitis. 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 documentation shows your doctor prescribed Diclofenac Sodium 3% gel to treat chronic pain syndrome, diabetic neuropathy, spondylosis of lumbar region, and right arm lymphedema and cellulitis. However, the Medicare approved compendia do not support the use of this drug for your conditions.A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium 3% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Synthroid 175-microgram tablet 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.Synthroid is a brand drug on Tier 3 of the plans formulary. The prescriber has not provided patient specific clinical rationale, with supporting medical documentation, to indicate that all alternatives required by the plan have been tried and failed, 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

You requested Prednisolone Acetate 1% suspension. There was no documented diagnosis. The Part D plan denied your tiering exception 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 asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the requested documentation.There were no medical records submitted supporting your condition. The QIC is unable to determine if your condition is a medically-accepted indication to support the use of the requested drug. Therefore, a tiering exception cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover Prednisolone Acetate 1% suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Flecaininde Acetate 100 milligram tablet prescribed twice daily for paroxysmal atrial fibrillation. 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. Flecaininde Acetate is a generic drug on Tier 3 of the plans formulary. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you. 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 milligram tablets prescribed for urgency of urination and overactive bladder. 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 ER is a brand name drug on Tier 4 of the plans formulary. There are no brand name 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 Rabeprazole Sodium DR 20 milligram tablets prescribed to treat gastroesophageal reflux disease. 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.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.A physician reviewed your appeal and determined that the plan is not required to cover Rabeprazole Sodium DR 20 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lotemax 0.5% eye drops prescribed daily for other nondiabetic proliferative retinopathy, cystoid macular degeneration, and other dystrophies primarily involving the sensory retina. 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 documentation shows your doctor prescribed Lotemax 0.5% eye drops to treat your nondiabetic proliferative retinopathy, cystoid macular degeneration, and other dystrophies primarily involving the sensory retina. No medical records were submitted. However, the Medicare approved compendia do not support the use of this drug for your condition(s). Please note the request for an off formulary exception for Lotemax 0.5% eye drops was not reviewed. We cannot consider an off formulary exception for a drug that is not supported by a covered diagnosis.A physician reviewed your appeal and determined that the plan is not required to cover Lotemax 0.5% eye drops.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligrams/2 milliliter syringe prescribed for severe persistent 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.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. The provided records do not validate that this enrollee is an oral corticosteroid dependent asthmatic or an eosinophilic phenotype. The medication list provided does not include oral steroids. Therefore, the requested drug, as ordered, is not being used for a medically accepted indication. The requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Verapamil Hydrochloride ER 120 milligram 24 hour extended release capsules prescribed daily for essential hypertension. 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 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. A physician reviewed your appeal and determined that the plan is not required to cover Verapamil Hydrochloride ER 24 hour extended release capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Linzess 145-microgram capsule to treat irritable bowel syndrome with constipation. 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.Linzess 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

You requested Cyclophosphamide 500 milligram capsules prescribed to treat amyloidosisassociated with multiple myeloma. 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 record shows the physician prescribed Cyclophosphamide oral capsules to treat amyloidosisassociated with multiple myeloma. However, this drug may be eligible for coverage under Medicare Part B. Oral drugs used for cancer treatment that contain the same active ingredient as the injectable dosage form are eligible for coverage under Medicare Part B. The requested drug has been prescribed for the treatment of cancer. In addition, the oral capsules prescribed contain the same active ingredient as the injectable dosage form of this medication. Therefore, this drug is not eligible for coverage under Medicare Part D.We determined that the plan is not required to cover Cyclophosphamide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 micrograms/actuation Inhaler. At initial determination and redetermination the diagnosis of shortness of breath was given. 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.At reconsideration, the diagnosis of chronic obstructive pulmonary disease was provided. Medical records were provided by the prescriber to support this diagnosis. The Medicare approved compendia contain citations to support the use of the requested drug, as prescribed, for the treatment of this condition. The requested drug is not on the plans formulary. 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.A physician reviewed your appeal and determined that the plan is not required to cover Anoro Ellipta 62.5-25 micrograms/actuation Inhaler.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zeposia 0.23-0.46 milligram starter pack capsules to treat multiple sclerosis. 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.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.A physician reviewed your appeal and determined that the plan is not required to cover Zeposia 0.23-0.46 milligram starter pack capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested AzaSite 1 percent drops prescribed for meibomian gland dysfunction. 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 documentation shows your doctor prescribed AzaSite to treat your meibomian gland dysfunction. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover AzaSite.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% Gel Pump. At initial determination and redetermination the diagnoses of late-onset (age-related) hypogonadism and testicular hypofunction were given. 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.At reconsideration diagnoses of hypogonadism and testicular hypofunction (E29.1) were given. No medical records were provided by the prescriber to support these diagnoses. The use of the requested drug to treat the provided diagnoses are off-label uses. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.