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

At issue is a request for coverage of Botox 200 unit per milliliter reconstituted solution prescribed for cervical dystonia. 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.Botox is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all the formulary alternatives included in the plan 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 1% Gel to treat pain secondary to osteoarthritis, bilateral hip. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Rivastigmine 9.5 milligram per 24 hour patches prescribed for Alzheimers disease.  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. During this review, a prescriber statement and supporting medical records were requested from the prescriber to address the tiering exception request. The prescriber responded to the request and submitted additional documentation.Rivastigmine is a generic drug on Tier 4 of the plan. The prescriber has not sufficiently addressed why the generic drugs of the same type on the lower tiers of the plans formulary to treat the noted condition have been tried and failed, or are contraindicated. A physician reviewed the appeal and determined that the plan is not required to cover the Rivastigmine patches at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Amphetamine-Dextroamphetamine 20 milligram tablets. The Part D plan denied the request for coverage.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 indicates that Amphetamine-Dextroamphetamine has been prescribed for poor cognitive function stemming from physical and neurological trauma resulting from a near-fatal motor vehicle accident. 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 noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and 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 Amphetamine-Dextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram oral capsule prescribed daily. 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. At initial determination the documentation indicated Dronabinol was prescribed to treat pain and improve quality of life. At reconsideration the physician submitted a supporting statement that shows Dronabinol was prescribed to treat nausea and vomiting caused by chemotherapy. However, the medical records submitted do not support chemotherapy is being used or that the enrollee had an inadequate response to conventional antiemetic treatments. Therefore,  the requested drug was prescribed for a non-medically accepted indication per the Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pegasys 180 micrograms/0.5 milliliters prescribed for chronic myelogenous (myeloid) leukemia. 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 records show you prescribed Pegasys 180 micrograms/0.5 milliliters to treat the enrollees chronic myeloid leukemia. However, the Medicare approved compendia and Medicare approved journals do not support the use of this drug for this condition. An oncologist reviewed your appeal and determined that the plan is not required to cover Pegasys 180 micrograms/0.5 milliliters.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Fluphenazine 5 milligram tablets prescribed for the enrollees condition. 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.Fluphenazine is a generic drug on Tier 4 of the plans formulary. The submitted documentation did not include a supporting statement. A request for additional information was sent to your doctor, and a supporting statement was received. The supporting statement does not address why all formulary 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, 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 Fentanyl 37.5-microgram/hour Patch to treat pain secondary to malignant neoplasm of middle third of esophagus. The case was auto-forwarded by the plan.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 a request for coverage of Pregabalin 100 milligram capsules, 120 capsules per 30 days, prescribed for progressive polyneuropathy. 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 part D plan has a quantity limit for Pregabalin 100 milligram capsules of 90 capsules per 30 days. The documentation does not support the necessity for exceeding the maximum dose allowed by the plan. It is noted that the formulary also includes Pregabalin capsules in the strengths of 150 milligram and 200 milligrams with a quantity limit of 90 capsules per 30 days. During this review, a request was sent to the prescriber to address the higher doses of Pregabalin to see if a fewer number of the larger strength of the Pregabalin capsules would be effective and appropriate to treat the enrollees medical condition. The prescriber responded to the request; however, the answers provided by the prescriber were not sufficient to grant an exception to the quantity limit criteria set by the plan. A physician reviewed your appeal and determined that the plan is not required to cover more than 90 capsules of 100 milligram Pregabalin per 30-day supply.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 88 microgram oral tablet. 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.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

At issue is a request for coverage of Doptelet 20 milligram tablets. The Part D plan denied the request because the plans prior authorization requirements were not satisfied. 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 indicates that Doptelet has been prescribed prior to a planned prostate biopsy procedure for an enrollee with chronic idiopathic thrombocytopenia. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for an enrollee with chronic idiopathic thrombocytopenia. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage under Medicare Part D, the plans prior authorization requirements will not be addressed. A physician reviewed your appeal and determined that the plan is not required to cover the Doptelet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carbamazeine ER 300 milligram capsules. 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.Carbamazeine ER is a generic drug on Tier 4 of the plans formulary. The prescriber indicates that one of plans alternative formulary drugs was 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 you.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 Budesonide 0.5 milligram/ 2 milliliter nebulizer solution prescribed for acute respiratory failure. The Part D plan denied your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows Budesonide 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 Budesonide. We determined that the plan is not required to cover Budesonide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Jakafi 5 milligram tablets prescribed as directed for STAT1-GOF; autoimmune hepatitis; lymphoproliferative disease; combined immunodeficiency;hypogammaglobulinemia; T-cell lymphopenia; and chronic mucocutaneous candidiasis. 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 Jakafi to treat your STAT1-GOF mutation associated with immune dysregulation. 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 Jakafi.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Venclexta 100 milligram tablet prescribed for relapsed/refractory myeloma with translocation 11;14. 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 records show you prescribed Venclexta 100 milligram tablet in conjunction with Kyprolis and Dexamethasone to treat the enrollees for relapsed/refractory myeloma with translocation 11;14. However, the Medicare approved compendia and Medicare approved journals do not support the use of this drug for this condition. An oncologist reviewed your appeal and determined that the plan is not required to cover Venclexta 100 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Invega Sustenna 234 milligram/milliliter intramuscular injection prescribed for the enrollees condition. 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.Invega Sustenna is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nucala 100 milligram/1 milliliter solution prescribed for moderate persistent asthma. 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 Nucala for moderate persistent asthma. The Medicare approved compendia do not support the use of the biologic at issue for your conditions. As it cannot be determined that the biologic was 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Eliquis 2.5 milligram tablets prescribed for an unknown condition. 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. The documentation does not include any medical records from the prescribing practitioner. A request was submitted to the prescriber to provide a diagnosis and supporting medical records. A reply from the prescriber was not received. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested is not eligible for coverage under Medicare Part D.  A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Unithroid 100 milligram tablets prescribed for the enrollees condition. 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.Unithroid is a brand drug on Tier 3 of the plans formulary. There are no 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 Corlanor 7.5 milligram tablets prescribe to treat chronic congestive heart failure and atrial premature depolarization. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. There was no evidence of an ejection fraction equal to or below 35% and a sinus rhythm with resting heart rate equal to or greater than 70 beats per minute. The prior authorization requirements were not met.A physician reviewed your appeal and determined that the plan is not required to cover Corlanor. 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 tiering exception request for Daptomycin for Solution to treat osteomyelitis. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.Our physician reviewer's opinion is that Specialty tier drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methocarbamol 500 milligram tablets prescribed for muscle spasms due to multiple sclerosis related nerve pain. 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. The submitted documentation indicates your doctor prescribed Methocarbamol for muscle spasms due to multiple sclerosis related nerve pain. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As it cannot be determined that the drug was 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 Modafinil 200 milligram oral tablet. 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 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.No diagnosis was submitted at initial determination. No medical records were submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia. The prior authorization requirements were not addressed because the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 milligram tablet. The Part D plan denied your request for a tiering exception.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.Jardiance 25 milligram tablet 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 Methocarbamol 500 milligram tablet prescribed for chronic myalgia. 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 records show you prescribed Methocarbamol 500 milligram tablet to treat the enrollees chronic myalgia. However, the 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 Methocarbamol 500 milligram tablet.