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

At issue is a tiering exception request for Rocklatan 0.02-0.005% ophthalmic solution prescribed as directed for primary open-angle glaucoma. 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 information submitted at the reconsideration level.Rocklatan 0.02-0.005% ophthalmic solution 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy to treat migraines. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Desvenlafaxine Succinate ER 50 milligrams.  At initial determination and redetermination the diagnosis of prostate cancer 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 a diagnosis of major depressive disorder was given. The medical records provided do not support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to Desvenlafaxine Succinate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trulicity 0.75 milligram/5 milliliter pen injector to treat Type 2 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.Trulicity 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 Metaxalone 800 milligram tablet to treat post-polio syndrome. 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: Favorable

At issue is Nuedexta 20 milligram-10 milligram capsules prescribed for the enrollees pseudobulbar affect. 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 enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee was prescribed Nuedexta for pseudobulbar affect. In addition, the medical records support the enrollee has amyotrophic lateral sclerosis.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Elmiron 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 reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xolair 150 milligram solution to treat chronic cough. 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 medical records support allergic rhinitis; however, the plan's prior authorization criteria are not met. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 20 milligram oral tablet prescribed daily for a personal history of pulmonary embolism. The Part D plan denied your request for a tiering exception. We received an expedited auto-forwarded reconsideration request from the plan. 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.Xarelto 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. There are no lower tiered brand drugs of the same type to treat the enrollee's condition.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 Tobramycin 300 milligrams per 5 milliliter inhalation nebulization solution prescribed for uncomplicated bronchiectasis related to a pseudomonas aeruginosa respiratory infection. 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 doctor prescribed Tobramycin for uncomplicated bronchiectasis related to a pseudomonas aeruginosa respiratory infection. However, this drug is eligible for coverage under Medicare Part B. Medicare Part B covers this drug for uncomplicated bronchiectasis related to a pseudomonas aeruginosa respiratory infection, when used with a nebulizer in the home (or in an assisted living facility). Medicare Part D cannot pay for drugs that are covered by Medicare Part B.We reviewed your appeal and determined that the plan is not required to cover Tobramycin nebulization solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucala 100 milligrams/milliliter Auto-Injector to treat severe persistent asthma. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. The enrollee does not have eosinophilic asthma. 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 Onglyza 5 milligram tablet to treat type 2 diabetes mellitus. The Part D plan denied the request because the information submitted does not support the medical necessity for use of both Onglyza and Trulicity. We received an auto-forwarded 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug. 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 Amphetamine-Dextroamphetamine to treat fatigue related to multiple sclerosis. 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 does 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

You requested Diclofenac Sodium 1% gel prescribed for lesion of ulnar nerve, right upper limb, and displaced fracture of the olecranon process without intraarticular extension of the right ulna. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Diclofenac Sodium 1% gel for lesion of ulnar nerve, right upper limb, and displaced fracture of the olecranon process without intraarticular extension of the right ulna. 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 Acthar gel to treat systemic lupus erythematosus. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80 milligrams/milliliter to treat plaque psoriasis. The Part D plan denied the 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 prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colistimethate (CBA) for Solution 150-milligrams to treat a chronic airway infection with pseudomonas aeruginosa. The Part D plan denied the request as prior authorization criteria were not met. 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 information provided indicates that the medication requested is to be inhaled via a nebulizer. Per the Medicare approved compendium, Micromedex, this drug is not FDA approved for use by inhalation via nebulizer. Non-FDA approved drugs are excluded from Medicare Part D coverage.  Our physician reviewer's opinion is that the plan is not required to cover this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine-Prilocaine 2.5%-2.5% cream prescribed for end-stage renal disease related services. The Part D plan denied the 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 record shows your doctor prescribed the drug for end-stage renal disease dialysis-related services. Dialysis-related medications are included in the bundled payment that Medicare pays to dialysis centers under Medicare Part B. Therefore, the drug at issue is not a Part D benefit. As the drug is not considered a Part D benefit, a quantity limit exception cannot be granted.We determined that the plan is not required to cover Lidocaine-Prilocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 150 micrograms to treat hypothyroidism. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocortisone-Iodoquinol Cream to treat perioral dermatitis. 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 plan denied the request for coverage of the requested drug to treat the provided diagnosis because the plans Medicare Part D drug plan cannot cover drugs classified as being part of the Food and Drug Administration (FDA)'s Drug Efficacy Study Implementation (DESI) program. These drugs are considered to be Less than Effective (LTE) per FDA review.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexlizet 180 milligram tablet to treat mixed hyperlipidemia. The requested drug is not on the plans formulary. The Part D plan denied the request as formulary exception criteria were not met. 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 Lidocaine 5 percent topical patch prescribed for pleurodynia and trochanteric bursitis, right hip. 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. 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 were prescribed for Lidocaine 5 percent topical patch for pleurodynia and trochanteric bursitis, right hip. In review of the Medicare approved compendia, pleurodynia and trochanteric bursitis, right hip are not medically accepted indications for Lidocaine 5 percent topical patch. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Lidocaine 5 percent topical patch at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Lyrica 100 milligram capsules for severe pain. 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 Repatha syringe 140 milligram/milliliter prescribed daily for unspecified hyperlipidemia. The Part D plan denied your request because 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 statement and medical records show Repatha was prescribed to treat unspecified hyperlipidemia. The Medicare approved compendia do not support the use of this drug for this condition. As such, the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. 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 Repatha.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Cinacalcet Hydrochloride 30 milligram tablets prescribed to treat hypercalcemia and secondary hyperparathyroidism in an enrollee who is status post a renal transplant. 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 documents submitted indicate the enrollee has undergone a renal transplant and has secondary hyperparathyroidism. The prescriber has indicated that the drug is being used to treat hypercalcemia in an enrollee who has undergone a renal transplant. Therefore, the prior authorization requirements were met. A physician reviewed your appeal and determined that the plan is required to cover Cinacalcet Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Vascepa 1 gram capsules, 4 capsules per day, to treat atherosclerotic heart disease of native coronary artery and hypertriglyceridemia. The Part D plan did not render a coverage determination. We received an auto-forwarded coverage determination request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. Vascepa 1 gram capsules are not included in the plans formulary. The prescriber has not sufficiently addressed why all alternative medications included in the plans formulary to treat the noted conditions 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 coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.