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

At issue is Tacrolimus 1% ointment to treat amyopathic dermatomyositis. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 a tiering exception for Repatha Sureclick 140 milligram/milliliter auto injector prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because Repatha is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Repatha is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spravato 56-milligram Spray to treat depression. 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.Non-FDA approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Celebrex 200 milligram capsules prescribed for degenerative arthritis. 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. Celebrex is not included in the plans formulary. While the plan has granted a non-formulary approval for the medication, the plan does not grant tiering exceptions for non-formulary drugs. Therefore, the Celebrex is not eligible for coverage at a lower-cost tier. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the Celebrex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dexilant DR 60 milligram capsules prescribed for gastroesophageal reflux disease without esophagitis. 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. Dexilant is a brand drug on Tier 2 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 Dupixent 300 milligram/2-milliliter pen injector prescribed for severe persistent asthma and allergic bronchopulmonary aspergillosis. The Part D plan denied your request for a tier change request because Dupixent is in the specialty tier of your list of covered drugs. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Dupixent is a brand name Tier 5 drug. Your plan does not allow you to receive drugs in this tier at a lower cost share.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Zolpidem Tartrate 10 milligram tablets prescribed for insomnia. The Part D plan forwarded the request to us for review.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. Zolpidem Tartrate is not included in the plans formulary. During this review, a prescriber statement and supporting medical records were requested from the prescriber to address the formulary alternatives. While the prescriber did send medical records, the prescriber did not address why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans 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 Istalol Solution prescribed once a day for your eye condition. The Part D plan denied your request. We received a reconsideration 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 the requested drug to treat your condition. The Medicare approved compendium supports the use of the requested drug for your condition. However, Istalol is not on your 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

At issue is Tacrolimus 0.1% ointment to treat lupus. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The 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

At issue is Tadalafil 10 milligram tablets to treat benign prostatic hyperplasia and erectile dysfunction. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed daily for non-24 hour sleep-wake disorder. 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. We did not receive the documentation requested. Your medical records show your doctor prescribed Hetlioz to treat your non-24 hour sleep-wake disorder. 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 Hetlioz. 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

You requested Sildenafil Citrate tablet prescribed for your condition. 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. We also researched Medicare systems and reviewed the enrollment data available. The submitted documentation does not include any medical records from your doctor stating what condition your medication is being prescribed for. Therefore, there is insufficient information to determine if the Sildenafil Citrate is being prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover the Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac sodium 3 percent gel prescribed as directed for migraines, degenerative joint disease, arthritis, chronic pain, occipital nerve entrapment with occipital neuralgia, and cervicalgia. 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. Your medical records show your doctor prescribed Diclofenac sodium 3 percent gel to treat your migraines, degenerative joint disease, arthritis, chronic pain, occipital nerve entrapment with occipital neuralgia, and cervicalgia. However, the Medicare approved compendia do not support the use of this drug for your conditions. 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 Diclofenac sodium 3 percent gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Namenda XR 7-14-21-28 milligram titration pack of oral capsules prescribed as directed for unspecified dementia, without behavioral disturbance. 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 Namenda XR for unspecified dementia, without behavioral disturbance. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Namenda XR.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Octreotide Acetate 100 microgram/milliliter solution prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because Octreotide Acetate is a generic Tier 4 drug and there are no generic drugs of the same type on the lower cost sharing levels. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Octreotide Acetate is a generic Tier 4 drug. There are no generic drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prednisolone Acetate powder, Gatifloxacin Powder, Bromfenac Sodium Powder, and Sterile Water Solution prescribed following cataract surgery. 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 QIC notes this drug is a compounded drug. Therefore, we reviewed each ingredient individually. Prednisolone Acetate Powder:We determined that the Medicare rules for this drug have not been met. The National Drug Code of a drug that has not been approved by the Food and Drug Administration do not meet the definition of a Part D Drug and are not eligible for coverage under the Part D Prescription Drug Benefit.Therefore, the plan is not required to cover the Prednisolone Acetate Powder ingredient included in the compound.Gatifloxacin Powder:We determined that the Medicare rules for this drug have not been met. The National Drug Code of a drug that has not been approved by the Food and Drug Administration do not meet the definition of a Part D Drug and are not eligible for coverage under the Part D Prescription Drug Benefit.Therefore, the plan is not required to cover the Gatifloxacin Powder ingredient included in the compound.Bromfenac Sodium Powder:We determined that the Medicare rules for this drug have not been met. The National Drug Code of a drug that has not been approved by the Food and Drug Administration do not meet the definition of a Part D Drug and are not eligible for coverage under the Part D Prescription Drug Benefit.Therefore, the plan is not required to cover the Bromfenac Sodium Powder ingredient included in the compound.Sterile Water Solution:Sterile Water Solution is excluded from Medicare Part D coverage, even when it is part of compound. Only Part D eligible drug product components are covered within a compoundTherefore, the plan is not required to cover the Sterile Water Solution ingredient included in the compound.The plan is not required to cover the compounded drug. This decision does not address the medical necessity of this drug. It only means that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Uptravi 1400 microgram tablets to treat pulmonary arterial hypertension. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has provided a statement that the enrollee does not have the dexterity or social support to manage the formulary alternatives, Treprostinil and Ventavis (Iloprost) However, the documentation does not address 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 Sirolimus 1 milligram tablet prescribe three times a day for an immunosuppressant agent in an enrollee status post a 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 also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia does 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 Sirolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate 0.083% 2.5 milligram/3 milliliter inhalation solution prescribed for pneumonia and wheezing. 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 is for use with a nebulizer in the enrollees 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

At issue is coverage for Armodafinil 150 milligram tablets. The Part D plan denied the request for coverage.  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 Armodafinil has been prescribed for multiple sclerosis related fatigue. However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, 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 Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lenvima 20 milligram capsules prescribed to treat advanced endometrial carcinoma. 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 Lenvima to treat your advanced endometrial carcinoma, microsatellite instability-high. 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 Lenvima.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Trulance 3 milligram tablets prescribed for chronic idiopathic constipation. The Part D plan denied the request for coverage.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.Trulance is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives included in the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans 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 Oxycontin 15 milligram extended release tablet prescribed for an unknown diagnosis. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration 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 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 Xembify 20% 10 grams/50 milliliter vial prescribed every three weeks to treat immunodeficiency with predominantly antibody defects. 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 prescriber was also asked questions to address the plans formulary alternatives. We did not receive the documentation requested.The medical records show your doctor prescribed Xembify to treat your condition. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Xembify.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rinvoq ER 15 milligram tablet to treat rheumatoid arthritis. 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 documentation provided addressed the plans coverage criteria and those criteria were not satisfied. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.