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

At issue is Invega Sustenna 156 milligrams/milliliter intramuscular injection prescribed every four weeks for schizoaffective 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 information submitted at the reconsideration level.Invega Sustenna 156 milligrams/milliliter intramuscular injection is a brand drug on Tier 5 of the plans formulary. Invega Sustenna 156 milligrams/milliliter intramuscular injection is on the specialty tier of the plans formulary. 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 Invega Sustenna 156 milligrams/milliliter intramuscular injection at a lower cost-share.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atorvastatin 40 milligram tablet prescribed to treat the enrollees condition. 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 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 prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the plans utilization management. A response from the prescriber was not received. Therefore, based upon the current record, 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 Atorvastatin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omeprazole 2 milligram/milliliter solution prescribed as directed for gastroesophageal reflux disease. 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. This drug is a compounded drug. Therefore, we reviewed each ingredient individually. The ingredients of the requested drug are: Omeprazole powder and over-the-counter ingredients. Omeprazole powder is considered a bulk powder. Bulk powders (i.e., Active Pharmaceutical Ingredients for compounding) do not satisfy the definition of a Part D drug and are not covered by Part D. Therefore, none of the ingredients of the requested drug are Part D drugs. Compounded medications that do not contain at least one ingredient that meets the definition of a Part D drug are excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligrams/milliliter injection to treat primary hyperlipidemia and atherosclerotic coronary vascular disease. 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and the coverage criteria are not satisfied by the provided medical records. 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 Imvexxy 10 microgram vaginal inserts to treat atrophic vaginitis. 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug. 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 Budesonide 0.5 milligram/2 milliliter nebulizer solution prescribed twice daily orally for lichen planus and dysphagia. 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 Budesonide to treat your lichen planus and dysphagia. The use of the requested drug to treat the provided diagnoses are 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 these conditions.  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 Budesonide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle Libre 14 Day reader device prescribed for your diabetes. Upon review, the Part D plan denied coverage because the Freestyle Libre 14 Day reader device is a medical supply that is specifically excluded from Part D coverage by Medicare law. Subsequently, the Part D Qualified Independent Contractor (QIC) received an expedited request from the appellant to reconsider the appeal. 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. Supplies for testing and monitoring blood glucose levels are not considered Part D drugs and may be covered under the Medicare Part B durable medical equipment benefit.In this instance, the QIC has determined that coverage cannot be allowed for the Freestyle Libre 14 Day reader device because the plan does not cover drugs/items excluded from Medicare Part D coverage. Medicare rules state that the definition of a Part D drug includes medical supplies directly associated with the injection of insulin. Test strips, lancets, and needle disposal systems are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. Therefore, the plan is not required to provide coverage for the Freestyle Libre 14 Day reader device. If the enrollee purchases drugs/items that are excluded, they must pay for them themselves. This decision does not address the medical necessity or appropriateness of the requested item. It only establishes that payment cannot be made under the Medicare Part D benefit.We determined that the plan is not required to cover the Freestyle Libre 14 Day reader device.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablets to treat autonomic dysfunction and postural orthostatic tachycardia syndrome. The Part D plan denied the request stating that the provided diagnoses are 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 diagnoses 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 these conditions. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz XR 22 milligram tablets to treat vitiligo. 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 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 Methylphenidate HCL ER 20 milligram tablets prescribed to treat hypersomnia 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 information submitted at the reconsideration level. 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 Methylphenidate HCL ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Oxycodone ER 40 milligram tablets prescribed for chronic pain 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 information submitted at the reconsideration level.Oxycodone ER is a generic drug on Tier 4 of the plans formulary. The prescribing physician has not sufficiently addressed why all of the generic drugs of the same type on the lower tiers of the plans formulary to treat the enrollees condition have been tried and failed, or are contraindicated.  A physician reviewed your appeal and determined that the plan is not required to cover the Oxycodone ER tablets at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tizanidine Hydrochloride 4-milligram capsule to treat muscle spasms of lower back with pain. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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 for relapsed refractory diffuse large B-cell lymphoma (C83.30). 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 records show you prescribed Calquence 100 milligram capsules to treat the enrollees refractory diffuse large B-cell lymphoma. However, the Medicare approved compendia and Medicare approved journals 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 Calquence 100 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Epipen 0.3 milligram/0.3 milliliter auto-injector to treat the enrollees condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.EpiPen auto-injector 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 to treat the same condition. 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 Vancomycin HCl 1.5 gram vial 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.Vancomycin HCl is a generic drug on Tier 4 of the plans formulary. There are no generic 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 Livalo 4 milligram tablets to treat hyperlipidemia. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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 Farxiga 10 milligram tablet prescribed for type 2 diabetes. 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.Farxiga 10 milligram tablet 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

You requested Trulicity 1.5 milligram/0.5 milliliter pen prescribed for type 2 diabetes. 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.Trulicity 1.5 milligram/0.5 milliliter pen is a brand biologic on Tier 3 of the plans formulary. There are no brand biologics of the same type on the lower cost sharing tiers. Therefore, this biologic 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 Eliquis 5-milligram tablet to treat 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.Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Depakote 500 milligram DR tablets prescribed for schizoaffective disorder, bipolar type. 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 Depakote DR tablets for schizoaffective disorder, bipolar type. The Medicare approved compendia do not support the use of the drug for your condition. 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 One Touch Ultra test strips prescribed for your diabetes. Upon review, the Part D plan denied coverage because the One Touch Ultra test strips are a medical supply that is specifically excluded from Part D coverage by Medicare law. Subsequently, the Part D Qualified Independent Contractor (QIC) 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. In this instance, the QIC has determined that coverage cannot be allowed for the One Touch Ultra test strips because the plan does not cover drugs/items excluded from Medicare Part D coverage. Medicare rules state that the definition of a Part D drug includes medical supplies directly associated with the injection of insulin. Test strips, lancets, and needle disposal systems are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. Therefore, the plan is not required to provide coverage for the One Touch Ultra test strips. If the enrollee purchases drugs/items that are excluded, they must pay for them themselves. This decision does not address the medical necessity or appropriateness of the requested item. It only establishes that payment cannot be made under the Medicare Part D benefit.We determined that the plan is not required to cover the One Touch Ultra test strips.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyanocobalamin 100 micrograms/milliliter injection prescribed for vitamin B12 deficiency. 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.We determined that the plan is not required to cover Cyanocobalamin because it was a prescription vitamin drug. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humulin U-500 milliliter vial prescribed for diabetes type two. 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 drug is given via an insulin pump and is subject to Part B. It is not eligible to be covered under the Medicare Part D prescription drug benefit. A physician reviewed your appeal and determined that the plan is not required to cover Humulin U-500 milliliter vial.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 2 milligram sublingual tablets prescribed as directed for pain related to lumbago, dorsalgia, and fibromyalgia. 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 documentation shows the doctor prescribed Buprenorphine Hydrochloride sublingual tablets to treat your condition. However, the Medicare approved compendia do not support the use of this drug in sublingual form for pain related to lumbago, dorsalgia, and fibromyalgia.A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Favorable

You requested Brukinsa 80 milligram capsules prescribed as directed for chronic lymphocytic leukemia. 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 enrollee has a biclonal hematologic disorder of chronic lymphocytic leukemia and lymphoplasmacytic lymphoma  versus marginal zone lymphoma. The enrollee was previously treated with Treanda and Rituxan in 2014, but experienced a recurrence in 2020. Treatment with Acalabrutinib was initiated, but the enrollee developed low platelets and diarrhea; therefore, the dosage was lowered and eventually treatment was discontinued due to intolerable side effects. The physician now recommends the use of Brukinsa for this enrollee.The National Comprehensive Cancer Network guidelines show a category 2A recommendation for Brukinsa in the treatment of chronic lymphocytic leukemia for individuals who could not tolerate other Brutons tyrosine kinase inhibitors. As such, the Medicare approved compendium does support the off-label use of this drug for the enrollees condition. In addition, an exception to the plans coverage criteria is medically necessary for this enrollee.A physician reviewed your appeal and determined that the plan is required to cover the Brukinsa.