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

At issue is Hetlioz 20 milligram tablet prescribed daily for circadian rhythm sleep disorder, free running type. 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. 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 received the documentation and included it in our review.The records show Hetlioz was prescribed to treat circadian rhythm sleep disorder, free running type. The Medicare approved compendia do support the use of this drug for this condition. However, the plan requires prior authorization criteria be met before they will cover the drug. The documentation provided does not show you have satisfied the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Norvasc 10 milligram tablets to treat hypertension. 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 formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Stiolto Respimat inhalation spray prescribed for chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception because Stiolto Respimat is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Stiolto Respimat is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Synthroid 137micrograms prescribed for hypothyroidism. The Part D plan denied your request for a tiering exception because Stiolto Respimat is a brand name Tier 4 drug and the lower cost-sharing tiers only contain generic alternative drugs. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Synthroid is a brand name Tier 4 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Butalbital/Acetaminophen/Caffeine 50/300/40 milligrams to treat intractable migraine with aura and cervicogenic headache. The Part D plan denied your request for a non-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The prescriber has not indicated why all alternatives which are 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 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 Entresto 24 milligram-26 milligram tablets for treatment of the enrollees condition. The Part D plan denied the request for a cost-sharing tier 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.Entresto is a brand drug on Tier 3 of the plans formulary. There are no brand name or generic 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 cost-sharing tier exception.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 Ofev 150 milligram capsules to treat systemic sclerosis associated with interstitial lung disease. 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 documentation does not satisfy the plans coverage criteria. The coverage criteria are not satisfied by the provided medical records. 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 Inlyta 5 milligram tablets prescribed as directed for an enrollee with aggressive mucosal melanoma. 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 the doctor prescribed Inlyta to treat aggressive mucosal melanoma. The enrollee was initially diagnosed with stage III disease in 2016. The enrollee underwent extensive facial surgery with radiation. In 2019, the enrollee was found to have metastatic disease involving the lung and breast; the enrollee underwent surgery. The enrollee experienced recurrence in the liver and was put in a Phase 1 trial with immunotherapy. Subsequently, the disease progressed and the enrollee was put in another Phase 1 trial. The disease has progressed further and the enrollee does not have a targetable mutation. The Journal of Clinical Oncology shows that those with mucosal melanoma had a 49% objective response rate to a Phase 1b study of Toripalamab (a PD-L1 inhibitor) with Inlyta. The Medicare approved compendia do support the off-label use of this drug for the enrollees condition.There is not an established standard of care for the treatment of mucosal melanoma. The enrollee has failed investigational and Food and Drug Administration approved therapies. The prescriber is basing the enrollees treatment plan on an ongoing Phase 3 combination clinical trial where the objective is progression-free survival with the specific combination of Inlyta plus immunotherapy with a PD-L1 inhibitor. An exception to the plans coverage criteria is medically necessary for this enrollee. A physician reviewed your appeal and determined that the plan is required to cover Inlyta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolic Acid to treat bilateral lung transplant status.  The Part D plan denied the request because the drug was not medically necessary. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug would be eligible for coverage under Part D.  There is no information in the Medicare Database that indicates you had a covered transplant paid for by Medicare. This drug in on the plans formulary. However, 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 Invokana 300 milligrams tablets to treat type 2 diabetes. The Part D plan denied your request for this drug because the step therapy requirements were not met. We received an expedited reconsideration request.We performed= an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The prescriber has not indicated that the enrollee has tried all alternatives required by the plans step therapy requirements, or why the plans required step therapy drugs would likely not be as effective for the enrollee as the requested drug. Our physician reviewer's opinion is that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Hydroxychloroquine 200 milligram tablet to treat the enrollees condition. The Part D plan denied the request. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Hydroxychloroquine 200 milligram tablet is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated if 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 Envarus extended release 1 milligram tablets prescribed daily for kidney transplant. The Part D plan denied your request because the enrollees transplant was in a Medicare approved facility covered by Part A. Therefore, anti-rejection drugs are covered under Part B. We received a reconsideration request. We received a case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is not required to cover the Envarus. Medicare records indicate the enrollee received kidney transplants on November 6, 2008 and February 6, 2021, which were covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Envarus is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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

At issue is Clonidine topical compound (Nifedipine 2 percent, Clonidine 0.2 percent, Baclofen 2 percent, Gabapentin 8 percent, Amitriptyline 2 percent, Lidocaine 2 percent, and Diclofenac 3 percent), prescribed for peripheral neuropathy. The Part D plan denied your request because the medication was excluded from coverage under Part D. The plan did not make a decision within the required timeframe. We received an 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. The documentation shows the physician had prescribed Clonidine topical compound  to treat peripheral neuropathy. The Medicare approved compendia does not support the use of the components of the Clonidine topical compound  for the enrollees condition. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Clonidine topical compound at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 0.5 milligram capsules prescribed daily for kidney transplant. The Part D plan denied your request because the enrollees transplant was in a Medicare approved facility covered by Part A. Therefore, anti-rejection drugs are covered under Part B. We received a reconsideration request. We received a case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is not required to cover the Tacrolimus Medicare records indicate the enrollee received a kidney transplant on November 28, 2012, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Tacrolimus is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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 a tiering exception request for Jardiance 10 milligram tablet to treat the enrollees condition. The Part D plan denied the request. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Jardiance 10 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 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 Acyclovir 5% cream prescribed twice daily to treat moderate to herpes zoster. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read 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 that your doctor prescribed Acyclovir to treat your condition. There are no medical records to support all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Acyclovir because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Amphetamine-Dextroamphetamine 20 milligram tablets to treat the diagnosis of attention deficit hyperactivity disorder. 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 medical record shows the requested drug has been prescribed for the enrollees condition. The requested drug is on the plans formulary. Detailed review of the CMS approved compendium, Micromedex, reveals the diagnosis of attention deficit hyperactivity disorder is a medically accepted indication for the use of Amphetamine-Dextroamphetamine. The documentation satisfies the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hyoscyamine Sulfate 0.125 milligram sublingual tablet to treat irritable bowel syndrome and colon spams. The Part D plan denied the request. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read 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 plan denied the request for coverage of the requested drug to treat the provided diagnosis because your plan's 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.A physician reviewed your appeal and determined that the plan is not required to cover the Hyoscyamine Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 1 milligram capsules prescribed as directed following a kidney transplant. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The record shows the physician prescribed Tacrolimus for the prevention of organ rejection after a kidney transplant. Medicare records show that this transplant was covered by Medicare Part A. Drugs used for immunosuppressive therapy following a Medicare covered transplant are eligible for coverage under Medicare Part B. Therefore, this drug is not eligible for Medicare Part D coverage.We determined that the plan is not required to cover Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil citrate 20 milligram tablets to treat the enrollees condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.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 25 milligram tablets prescribed daily for Raynauds syndrome without gangrene. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Sildenafil for Raynauds syndrome without gangrene. We asked your doctor to send us a supporting statement to show why Synthroid is medically necessary for you. No additional documentation was received.In review of the Medicare approved compendia, Raynauds syndrome without gangrene is not a medically accepted indication for Sildenafil. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Sildenafil at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Flovent Diskus 100 microgram blister with inhalation device prescribed for shortness of breath and chronic heart failure. The Part D plan denied your request for a tiering exception because Flovent Diskus is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Flovent Diskus is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Baclofen 50 milligram tablets to treat muscle spasms. 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.Baclofen is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated if 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 Polyethylene glycol 3350 17 gram oral powder packets prescribed to treat constipation. The plan denied your request because Medicare excludes nonprescription drugs from Part D coverage. We received a reconsideration request.We received a 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.According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover Polyethylene glycol oral powder packets.