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

You requested coverage for Tadalafil 20 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 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 Tadalafil is being prescribed to decrease pulmonary vascular resistance in an enrollee who has a history of congenital heart defect with tricuspid atresia status post Fontan procedure in 1987, and Fontan revision in 2006. 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 your appeal and determined that the plan is not required to cover the Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine hydrochloride 10 milligram tablets prescribed as directed for 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. We asked the prescriber to send us medical records and a supporting statement showing the medical necessity of Cyclobenzaprine hydrochloride. However, we did not receive the documentation.The available documentation does not contain medical records. 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 Cyclobenzaprine hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trintellix 20 milligram tablet prescribed as directed to treat major depressive disorder. 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 records submitted at the reconsideration levelThe medical records show you were prescribed Trintellix to treat your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has been met. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover Trintellix.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Xifaxan 550 milligram tablets prescribed for irritable bowel syndrome with diarrhea. The Part D plan denied your request because the prior authorization requirements were not met.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 answers to the prior authorization requirement questions have been changed at reconsideration. However, a signed prescriber statement has not been submitted to validate the change in answers. Additionally, the submitted medical records do not sufficiently address the prior authorization requirements. Therefore, it is not possible to determine if the plans requirements or exclusions 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

At issue is Risedronate Sodium 150 milligram tablets to treat the enrollees 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.Risedronate Sodium 150 milligram tablets is not on the plans formulary.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

You requested Calquence 100 milligram capsules prescribed as directed for an enrollee with newly diagnosed mantle 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. The record shows the physician prescribed Calquence for an enrollee with newly diagnosed mantle cell lymphoma. The documentation does not show that the enrollee has received prior treatment for their condition. The physician states that other treatment options for first line treatment of mantle cell lymphoma will be too toxic for this elderly enrollee. However, the Medicare approved compendia do not support the use of Calquence as first line treatment for mantle cell lymphoma. A physician reviewed your appeal and determined that the plan is not required to cover Calquence.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate 2.5 milligram/3 milliliter nebulizer solution. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The drug at issue was prescribed for use with a nebulizer machine in your home. This is eligible for coverage under Part B. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Albuterol Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cinacalcet 60 milligram tablets prescribed daily for treatment of secondary hyperparathyroidism of end stage renal disease. 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, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. End stage renal disease bundle includes all end stage renal disease-related drugs and biologicals, regardless of whether or not these are furnished by a dialysis facility. We determined that the plan is not required to cover the Cinacalcet. Drugs which are eligible for Part B coverage are excluded from Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stelara 90 milligram/milliliter injection prescribed as directed for hidradenitis suppurativa. 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 medical records show your doctor prescribed Stelara to treat your condition. 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 the Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tymlos solution pen-injector 80 micrograms to treat age-related osteoporosis with current pathological fracture. 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 also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Tymlos.A physician reviewed your appeal and determined that the plan is not required to cover Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate 500 milligram tablet, two tablets twice a day, to treat granulomatosis with polyangiitis. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.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 your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Buprenorphine Hydrochloride 20 milligram sublingual 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 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 Buprenorphine Hydrochloride sublingual tablets have been prescribed for long-term opiate use due to chronic pain and fibromyalgia related to multiple chronic musculoskeletal conditions. 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 your appeal and determined that the plan is not required to cover the Buprenorphine Hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle Libre 14 Day Reader Device prescribed for monitoring your blood glucose levels. The Part D plan denied the appeal because glucose reader devices are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. We received an auto forwarded 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. Your medical record shows that you are a person with diabetes. Glucose monitoring supplies are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Medicare Part D. As such, the Freestyle Libre 14 Day Reader Device is excluded from Part D coverage by Medicare law.We have determined that your plan is not required to cover Freestyle Libre 14 Day Reader Device. Medicare Part B/Durable Medical Equipment is responsible.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kesimpta Solution Auto-Injector 20-milligram/0.4 milliliter to treat pemphigus foliaceus. 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.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

You requested Nuedexta 20-10 milligram oral capsule prescribed twice daily. The Part D plan denied your request. 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. The medical records submitted indicate Nuedexta was prescribed to treat vascular dementia with behavioral disturbance. However, the Medicare approved compendia do not support the use of this drug for this condition. As such, the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. A physician reviewed your appeal and determined that the plan is not required to cover Nuedexta. The requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% patch prescribed as directed for acute lower back pain due to strain. 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. No medical records were provided by the prescriber. 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 the Diclofenac Epolamine patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Doxycycline 50 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 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. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, documentation was provided showing that the Doxycycline was not covered by the plan at the time of purchase, and you were charged based on the contracted price for the prescription. We determined that the plan is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Memantine HCL ER capsules prescribed as directed for dementia. 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 being covered by the plan at the Tier 3 copay level for an enrollee who qualifies for the Low Income Subsidy. Drugs approved for members who qualify for the Low Income Subsidy are already provided at the lowest cost available. 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 tiering exception request for Pyridostigmine Extended Release 180 milligram tablets for myasthenia gravis exacerbation. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Latuda 40 milligram tablets prescribed daily for schizoaffective disorder, unspecified, and bipolar disorder. The Part D plan denied your 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. Latuda is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Pushtronex system solution cartridge 420 milligrams/3.5 milliliters prescribed as directed to treat hyperlipidemia. 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 records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Repatha Pushtronex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Botox Cosmetic 100 unit vial prescribed as directed for migraines. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The record shows you were prescribed Botox Cosmetic for migraines. The Medicare approved compendia do not support the use of this drug for your condition. Also, the plan has indicated Botox Cosmetic was denied during their review; however, the regular formulation has been approved. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Botox cosmetic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Savaysa 60 milligram prescribed for your anti-coagulation therapy. 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 records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Savaysa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Leflunomide 10 milligram tablets prescribed for seropositive rheumatoid arthritis. 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.Leflunomide is a generic drug on Tier 3 of the plans formulary. There are three generic drugs of the same type on the lower tiers of the plans formulary. They are Methotrexate, Sulfasalazine, and Azathloprine. The prescribing physician has addressed these alternatives at reconsideration noting that the enrollee is already taking Methotrexate and cannot take Sulfasalazine due to a documented allergy to sulfa drugs. The prescriber has noted that Azathloprine is generally not effective for the treatment of rheumatoid arthritis and also generally not combined with methotrexate due to risk of hepatotoxicity. However, the Medicare approved compendia include Azathloprine as an effective treatment for rheumatoid arthritis. Furthermore, both Azathloprine and Leflunomide when combined with methotrexate increase the risk of hepatotoxicity.  Therefore, the prescriber has not sufficiently addressed why the lower-cost Azathloprine is contraindicated. A physician reviewed your appeal and determined that the plan is not required to cover the Leflunomide at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spiriva Handihaler 18 microgram capsule to treat severe persistent asthma. 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.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Repatha 140 milligram per 1 milliliter subcuataneous injection pen prescribed for hyperlipidemia and coronary artery disease. 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.Repatha is not included in the plans formulary. The prescriber has not sufficiently addressed why all alternative medications that are included in the plans formulary to treat the noted conditions would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.