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

You requested coverage for Prolastin-C 1000 milligram per 2 milliliter intravenous solution prescribed for emphysema and alpha-1-antitrypsin deficiency. 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 does not satisfy the plans coverage criteria. The submitted medical records do not support that all of the plans requirements for coverage of this medication have been met. 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 Anoro Ellipta 62.5-25 microgram inhaler prescribed for pulmonary emphysema. 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 Anoro Ellipta for pulmonary emphysema and the formulary alternatives were tried and failed. However, there were no medical records submitted to support a covered diagnosis or to support the formulary alternatives were tried and failed. 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

At issue is a tiering exception request for Myrbetriq 50 milligram ER 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.Myrbetriq is a brand drug on Tier 4 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 Hetlioz 20 milligram capsule. 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 Hetlioz to treat non-24 hour sleep wake cycle, circadian rhythm sleep disorder. The Medicare approved compendia do support the use of this drug for your condition. However, medical records have not been provided; therefore, the documentation does not satisfy the plans coverage criteria. A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cinacalcet 30 mg tablet prescribed for hypercalcemia of malignancy with B cell lymphoma. 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.Your medical records show your doctor prescribed Cinacalcet 30 mg tablet to treat your hypercalcemia of malignancy. The medical records submitted indicate that you also have B cell lymphoma. 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 Cinacalcet 30 mg tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Vimpat 100 milligram tablets prescribed for a seizure disorder. 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. Vimpat is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover Vimpat at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methotrexate 2.5 milligram tablets prescribed as directed. 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 the prescriber to send us medical records to support the medical necessity of the requested drug. However, we did not receive the documentation.No medical records were provided by the prescriber to support the enrollees diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, 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 Methotrexate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Entresto 4-51 milligram tablets prescribed for unknown diagnosis. 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 plan has approved payment for the drug at issue. You were in the coverage gap stage of your prescription drug plan. The plans Evidence of Coverage indicates your financial responsibility in the coverage gap stage for brand name drugs is 25% of the approved cost for a 30 day supply. However, you are requesting coverage for a 90 day supply. Therefore, we determined the plan was correct in its calculation of coinsurance and is not required to cover Entresto at a lower cost share.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vitamin D3 25 microgram tablet prescribed daily for vitamin D deficiency. The Part D plan denied your request because Medicare has excluded Part D coverage for prescription vitamin and mineral products. We received a reconsideration request. We performed and 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 Vitamin D3 because prescription vitamin and mineral products are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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 Xifaxan 550 milligram tablets prescribed twice daily for hepatic encephalopathy. 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.Xifaxan is on the specialty tier of your plans formulary. Specialty tier drugs are not available for a tiering exception per Medicare rules.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 Nexlizet 180-10 milligram tablets. 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 Nexlizet was prescribed; however, Micardis is a non-formulary approved drug and is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the Nexlizet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Tacrolimus 1 milligram capsules prescribed daily following a kidney transplant. 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. We also researched Medicare systems and reviewed the enrollment data available. Your records show your doctor prescribed Tacrolimus to prevent rejection following a kidney transplant. The Medicare approved compendia support the use of this drug for your condition. Based on the information provided, the drug is eligible for Part B coverage. Therefore, the drug is not eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is not required to cover Tacrolimus for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexium 40 milligram DR capsules prescribed two times daily 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.Nexium DR is a non-formulary brand drug. Non-formulary drugs 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

At issue is a tiering exception request for Sunosi 75 milligram tablets prescribed for sleepiness and fatigue related to narcolepsy. 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

At issue is Nucynta 100 milligram ER tablets prescribed for chronic knee and shoulder 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. 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 reimbursement for Gaviscon liquid. 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. Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.We determined that the plan is not required to cover Gaviscon liquid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide EC 3 milligram capsule to treat collagenous colitis. 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 indicates that this drug is approved as a recurring 90 day supply. This is the maximum recurring supply amount allowed by the plan. In conclusion, our decision is unfavorable.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Repatha SureClick 140 milligrams per milliliter subcutaneous injection pen prescribed for coronary artery disease and hyperlipidemia. 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.Repatha is a biologic drug on Tier 3 of the plans formulary. There are no biologic drugs of the same type on the lower cost sharing tiers. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Repatha at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tretinoin 0.025% gel prescribed for acne rosacea. 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 originally prescribed Tretinoin for acne rosacea. The Medicare approved compendia do not support the use of this drug for your condition. Your doctor submitted a statement to indicate the diagnosis submitted should be changed to acne vulgaris and actinic keratoses. However, there were no medical records submitted to corroborate the change in diagnosis. A request for medical records was submitted to your doctor; however, no medical records were submitted. Therefore, the change in diagnosis cannot be performed. 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

At issue is Dextroamphetamine 10 milligram extended-release oral capsules prescribed for narcolepsy with cataplexy. 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 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 submitted a supporting statement that indicates Dextroamphetamine extended-release oral capsule was prescribed to treat narcolepsy with cataplexy and that the enrollee had already tried Armodafinil, Ritalin, and Adderall without success. However, the records do not show why the enrollee cannot take Dextroamphetamine Sulfate oral tablet, a preferred drug on the plans formulary for the condition. A physician reviewed your appeal and determined that the plan is not required to cover Dextroamphetamine 10 milligram extended-release oral capsules.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Gabapentin 800 milligram tablet 180 tablets per 30 days to treat focal epilepsy. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this quantity of medication was needed. We received the documentation and included it in our review.The plan limits the amount of Gabapentin 800 milligram tablet to 120 tablets per 30 days. The prescriber has indicated that the number of doses of the requested drug allowed by the plan has not been effective in treating the condition. Therefore, an exception to the plans quantity limit coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Exemestane 25 milligram tablet prescribed for breast cancer. 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.Exemestane 25 milligram tablet is a generic drug on Tier 4 of the plans formulary. Your doctor submitted a supporting statement and medical records. The records indicate that Letrozole was tried and failed, which is the same class as Exemestane 25 milligram tablet, on Tier 2. However, the plans formulary also includes Anastrozole, which is the same class as Exemestane 25 milligram tablet, on Tier 1. Your doctor did not address why the Anastrozole would not work for you. All generic drugs on lower tiers have not been tried. 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 Edarbi 80 milligram tablets prescribed for essential hypertension. 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. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Edarbi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 20-milligram 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.Xarelto 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

You requested Gleostine 100 milligram capsules prescribed as directed for glioblastoma. 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.According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the March 2021 published list, the manufacturer of Gleostine has not signed the agreement and does participate in the Medicare Gap Discount Program. We reviewed your appeal and determined that the plan is not required to cover the Gleostine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 2 milligram tablet to treat hyperlipidemia. 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Lynparza 100 milligram tablet prescribed for isocitrate dehydrogenase mutant astrocytoma.  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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  As such, an exceptions request based on medical necessity cannot be considered because 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.