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

At issue is Tadalafil 5 milligram tablets prescribed to treat benign prostatic hyperplasia with nocturia. 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.Tadalafil is on the plans formulary to treat the diagnosis of pulmonary hypertension only. Tadalafil is not on the plans formulary to treat your condition. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you.A physician reviewed your appeal and determined that the plan is not required to cover Tadalafil 5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide bulk powder/Dextrose anhydrous powder (compound) to treat your condition. 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 show you were prescribed Budesonide bulk powder/Dextrose anhydrous powder (compound). Drugs compound from bulk powder are not FDA approved and are not covered under Part D. Therefore, the plan is not required to cover Budesonide bulk powder/Dextrose anhydrous powder (compound).A physician reviewed your appeal and determined that the plan is not required to Budesonide bulk powder/Dextrose anhydrous powder (compound).
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Propranolol Extended Release 60 milligram capsule prescribed daily to treat the enrollee's condition. 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. Propranolol Extended Release 60 milligram capsule is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omnipod Dash 5 pack pods prescribed for adrenal insufficiency. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows your doctor prescribed Omnipod Dash 5 pack pods to treat your adrenal insufficiency with Solu-Cortef. However, these supplies may be eligible for coverage under Medicare Part B. We determined that the plan is not required to cover Omnipod Dash 5 pack pods.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aubagio 14 milligram tablet prescribed for relapsing remitting multiple sclerosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. A doctors statement shows Aubagio was prescribed for relapsing remitting multiple sclerosis. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation from the prescriber does not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Aubagio.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vraylar 1.5 milligram capsules prescribed for major depressive disorder. 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 Vraylar for major depressive disorder. 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 Temozolomide 140 milligram capsules prescribed daily for a glioblastoma. We received an auto-forwarded reconsideration request from the coverage level.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 doctor submitted a supporting statement to indicate the drug at issue is prescribed for a glioblastoma. However, there were no medical records submitted to support the diagnosis or how the drug at issue will be used as treatment. As it cannot be determined that the 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 Januvia 100 milligram oral tablet prescribed daily for diabetes. 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. Januvia 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: Favorable

You requested Octreotide Acetate 100 microgram/milliliter solution prescribed for postprandial hypoglycemia. 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 medical records show your doctor prescribed Octreotide Acetate for postprandial hypoglycemia. The records indicate you have a history of severe postprandial hypoglycemia. The Medicare approved compendium contain a reference to support the use of the drug for your condition. A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spravato 56 milligram dose pack prescribed for severe depression. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is included on Tier 5 of the plans formulary. This Tier is identified as a Specialty Tier. The plan is not required to grant a tier exception for drugs available on their Specialty Tier. Therefore, a tier exception cannot be considered.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nubeqa 300 milligram tablets prescribed for metastatic castrate-resistant prostate cancer. 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 Nubeqa for metastatic castrate-resistant prostate cancer. 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 Rituxan 100 milligram/10 milliliter solution prescribed for lung transplant status, lung transplant rejection, pulmonary fibrosis, unspecified. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows your doctor prescribed Rituxan to treat your lung transplant status, lung transplant rejection, pulmonary fibrosis, unspecified. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Rituxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nulojix 250 milligram/vial prescribed for post kidney transplant. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We determined that the drug is eligible for Part B coverage. The beneficiary had a Medicare-covered transplant on November 28, 2020. Therefore, the drug can be considered for payment under the Part B benefit.A physician reviewed your appeal and determined that the plan is not required to cover Nulojix.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methamphetamine Hydrochloride 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.Methamphetamine Hydrochloride 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

You requested Humira 40 milligram/0.4 milliliter pen injector was prescribed to treat sarcoidosis. The Part D plan denied your 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.The prescriber statement and medical records show Humira was prescribed to treat sarcoidosis. 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 Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 0.25 milligram or 0.5 milligram solution pen injector prescribed for the enrollees condition. 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. Ozempic 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 Kevzara 200 milligrams per 1.14 milliliters solution auto-injector prescribed to treat rheumatoid arthritis and systemic lupus erythematosus.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Kevzara 200 milligrams per 1.14 milliliters solution auto-injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin ER 10 milligram tablet prescribed for lumbar radiculopathy and low back pain. 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. A doctors statement and medical records show Oxycontin was prescribed for lumbar radiculopathy and low back pain. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation from the prescriber does not support why all drugs on the plans formulary would not work for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Oxycontin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Dofetilide 500-microgram capsule to treat the enrollees atrial fibrillation. 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.Dofetilide is a generic drug on Tier 4 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

At issue is Xiidra 5% eye drops prescribed for dry eye syndrome. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your prescriber indicates you have tried over the counter artificial tears and are allergic to Lotemax. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria. There is no documentation that you have had 90 days of consecutive therapy in the pasy 12 months, contraindication, or intolerance to Restasis. A physician reviewed your appeal and determined that the plan is not required to cover Xiidra eye drops. 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 Trelegy Ellipta 100-62.5-25 microgram inhaler prescribed for chronic obstructive pulmonary disease. 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. Trelegy Ellipta is a brand name drug on Tier 3 of the plans formulary. There are no brand name drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temazepam 30 milligram capsules prescribed to help with the enrollees sleep. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.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. Your medical records show your doctor prescribed Temazepam to help with the enrollees sleep. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Temazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ambisome 50 milligram vial prescribed as an inhaled medication through a nebulizer to treat an aspergillus infection with a surgical history of a double lung transplant. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We determined that the drug is not eligible for Part D coverage. According to DrugDex and the FDA label for Ambisome, this drug is given by injection into a vein. The medical records show your doctor prescribed Ambisome 50 milligram vial as an inhalation medication through a nebulizer to treat an aspergillus infection. 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 Ambisome 50 milligram vial.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20 milligram tablets prescribed for pulmonary hypertension. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We requested additional documentation from your prescriber. Your prescriber indicates he is prescribing Sildenafil 20 milligram tablets to be taken as 1 tablet 3 times a day for a total of 90 tablets per 30 days to treat pulmonary hypertension. However, we also requested medical records to support the diagnosis and none were submitted. We are unable to verify the diagnosis and if Medicare compendia support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prolia 60 milligram/milliliter injection prescribed every 6 months for osteoporosis. 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 Prolia to treat your osteoporosis. However, the prescriber has not indicated that all alternatives required by the plan have been tried and failed, or why the plans required step therapy drugs would likely not be as effective 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: Favorable

At issue is Cabometyx 60 milligram tablets prescribed for metastatic renal cell carcinoma. The Part D plan denied coverage.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 Cabometyx for metastatic renal cell carcinoma. The submitted medical records support the drug at issue will be given as a monotherapy after the enrollee had progressed on immunotherapy agents.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Zelboraf 240 milligram tablets prescribed for metastatic melanoma. The Part D plan denied coverage.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 Zelboraf to treat metastatic melanoma, BRAF amplification positive. The prescriber now indicates the drug at issue will be given in combination with Cotellic and that Mekinist will be discontinued.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.