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

At issue is Febuxostat 40 milligram tablets to treat gout. The Part D plan denied your request for a tiering exception. 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 prescriber indicates the Allopurinol, Colchicine, Colcrys and Probenecid are all unable to be taken by the enrollee due to her current renal function. The prescriber also states that the dose of Allopurinol required to lower her uric acid level would be too high for her renal impairment.  However, there was insufficient medical records submitted to support the enrollees renal status or the dosage of Allopurinal that the prescriber felt was required. 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 Lumigan 0.01% solution, eye drops prescribed to treat primary open-angle glaucoma. The Part D plan denied your request for a tier exception. 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.The record shows the requested drug was being prescribed to treat the provided diagnosis. Lumigan 0.01% solution is a brand name on Tier 3 of the plans formulary. There are no brand drugs of the same type available on the lower cost-sharing tier to treat the enrollees condition. We have determined that the plan is not required to provide a tiering exception.A physician reviewed your appeal and determined that the requested drug is not eligible for coverage under Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nuedexta capsules 20-10 milligrams to treat pseudobulbar affect secondary to head injury. 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 use of the requested drug to treat the provided diagnosis is a labeled use per the Food and Drug Administration labeling. The Medicare approved compendia contain citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Per the compendia, The fixed combination of dextromethorphan hydrobromide and quinidine sulfate (dextromethorphan/quinidine; commercially available as Nuedexta) is used in the treatment of pseudobulbar affect in adults. Pseudobulbar affect occurs secondary to various otherwise unrelated neurologic conditions (e.g., amyotrophic lateral sclerosis, multiple sclerosis, dementia of the Alzheimer's type or other dementia, parkinsonian syndrome, stroke, traumatic brain injury) and is characterized by involuntary, sudden, uncontrollable, and frequent episodes of laughing and/or crying. These episodes typically occur out of proportion or incongruent to the underlying emotional state. Pseudobulbar affect episodes often cause severe embarrassment and social dysfunction, which can lead to social isolation, impaired function, and reduced quality of life. Therefore, the requested drug is eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Prograf 1 milligram capsule for post heart transplantation. 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 Vimpat, 50-milligram tablet prescribed one tablet twice a day for seizures. You asked the Part D plan to provide a cost-sharing tiering exception. The plan denied the appeal because there are no brand name drugs in the lower cost-sharing tiers that treat your condition. 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. Your medical records show Vimpat is being prescribed for seizures. A Medicare approved compendium supports the use of the requested drug for your condition. Vimpat 50-milligram tablet is a brand name drug on Tier 3 of your plan's formulary. 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 cost-sharing tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Vimpat because there are no brand name drugs in the lower cost-sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol 180 milligrams prescribed to treat pure hypercholesterolemia. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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. Nexletol is a non-formulary drug. We requested information as to why plans formulary alternatives are not medically appropriate to treat the enrollees condition. The prescriber did not address why the enrollee cannot take other antihyperlipidemic drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Nexletol
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine-dextroamphetamine 30 milligram tablets prescribed as directed for hypersomnia following a traumatic brain injury. The Part D plan denied your request because drug was not prescribed for a medically accepted indication. 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. The documentation shows the doctor prescribed Amphetamine-dextroamphetamine for hypersomnia following a traumatic brain injury. However, the Medicare approved compendia do not support the use of this drug for hypersomnia following a traumatic brain injury.A physician reviewed your appeal and determined that the plan is not required to cover Amphetamine-dextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Opsumit, 10 milligram tablets prescribed daily for the treatment of pulmonary artery hypertension. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Opsumit as an off-formulary exception.The submitted medical records show that Opsumit was prescribed to treat the enrollees pulmonary artery hypertension. The Medicare approved compendia support the use of the requested drug for this condition. However, the submitted documentation does not sufficiently address why all of the alternative drugs listed in the plans formulary to treat pulmonary artery hypertension have not been tried, or are contraindicated. Therefore, the plan will not cover the Opsumit as an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Lantus 100 units/milliliter vial to treat Type 2 diabetes mellitus.   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.Lantus 100 units/milliliter vial is a biologic drug on Tier 3 of the plans formulary. There are no biologic 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 Repatha 140 milligram/milliliter SureClick injection pen prescribed as directed for hyperlipidemia. The Part D plan denied coverage because the prior authorization criteria were not met. 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. Your medical records show you were prescribed Repatha for hyperlipidemia. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided do not show the plan's coverage criteria has been met.A physician reviewed your appeal and determined that the plan is not required to cover the Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil Citrate 20 milligram tablets. The Part D plan denied coverage because the prescriber indicated the drug is not prescribed for pulmonary artery hypertension on the prior authorization application. We received an auto-forwarded reconsideration request from the plan because they did not make a timely decision. 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 requested your doctor provide medical records and a provider statement to support coverage criteria for the drug at issue. We did not receive the required documentation.A physician reviewed this decision and determined that the plan is not required to cover Sildenafil Citrate because your doctor indicated it was not prescribed for pulmonary artery hypertension. 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 Piqray 250 milligram tablets prescribed as directed for your condition. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. 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. Piqray is a brand drug on Tier 5, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the specialty tier from the tiering exception process. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Piqray. A tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide EC 3 milligram capsules for graft-versus-host disease. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. 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 medical records show Budesonide was prescribed for graft-versus host disease. The Medicare approved compendia do not support the use of this drug for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to Budesonide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Neupro, 8-milligrams, 24-hour transdermal patch prescribed one daily for Parkinsons disease. The plan denied the request because there are no other brand drugs, appropriate to treat your diagnosis or condition, on a lower cost-sharing tier. The drug you requested is already being provided to you at the lowest cost-share amount allowed by your plan. 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. Your medical records show Neupro is being prescribed for your Parkinsons disease. A Medicare approved compendium supports the use of the requested drug for your condition. However, Vimpat is a brand name drug on Tier 4 of your plan's formulary. There are no brand name drugs of the same type on the lower cost-sharing levels to treat your condition. Therefore, the requested drug is not eligible for a cost-sharing tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Neupro because there are no brand name drugs on the lower cost-sharing tiers of the same type to treat your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tretinoin 0.05% gel prescribed daily for hidradenitis suppurativa. The Part D plan denied your request because drug was not prescribed for a medically accepted indication. 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 medical records show Tretinoin was prescribed to treat hidradenitis suppurativa. The prescriber statement indicates the enrollee was diagnosed with Hurley Stage III hidradenitis suppurativa that causes severe pain which interferes with their daily quality of life. Previous treatments tried include Humira, Doxycycline, Triamcinolone cream, Amoxicillin, Keflex, and Bactrim. However, the Medicare approved compendia do not support the use of Tretinoin gel for this condition. The drug was not prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Tretinoin 0.05% gel.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Dupixent 300 milligrams/two milliliters syringe for the diagnoses of bullous pemphigoid. The Part D plan denied your request because this drug is not medically accepted for this condition. 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 also researched Medicare regulations and Medicare approved compendia. The Medicare approved compendia does contain citations to support the Food and Drug Administration has granted an orphan drug designation for the treatment of bullous pemphigoid. Therefore, the requested drug is eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Adakveo 100 milligram/10 milliliter solution  prescribed for sickle cell anemia. 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. The record shows the drug was supplied by the prescriber and administered to the enrollee in the prescribers office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. No additional documentation was requested from the prescriber. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Adakveo. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise ER 600 milligram tablets to treat neuropathic pain associated with lumbar radiculopathy, peripheral neuropathy, osteoarthritis, degenerative joint disease, and spinal stenosis. The Part D plan denied the request stating that the provided diagnosis is a not a 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 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: Favorable

At issue is Xiidra 5 percent eye solution to treat dry eyes.   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.In the Reconsideration appeal dated February 19, 2021 the prescriber stated that the enrollee tried and failed Restasis prior to 2017 and that the enrollee has bilateral scarring due to Dry eye disease.  The prescriber has indicated why all alternatives required by the Plan would likely not be as effective as the requested drug for you, or would likely cause adverse reaction(s). Therefore, an exception to the Plans 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

At issue is Alprazolam 1 milligram tablets to treat your essential tremor. The Part D plan denied the request stating that the provided diagnosis is not a 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 record shows you were prescribed Alprazolam for essential tremor. In review of the Medicare approved compendia, essential tremor is not a medically accepted indication for Alprazolam. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Alprazolam at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nulojix. 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 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 may be eligible for coverage under Part B under Medicare rules.   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 Contour Next Test Strips prescribed for glucose monitoring. The Part D plan denied your request to cover the test strips under Part D. 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 other information submitted at the reconsideration level.The record shows that your doctor prescribed Contour Next Test Strips to test your glucose levels due to diabetes mellitus type two. Glucose test strips are covered under Medicare Part B.  Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law. As such, our decision is that the Part D plan is not required to cover the Contour Next Test Strips. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit.