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

At issue is Januvia 100 milligram tablets prescribed daily. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Januvia is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Entresto 24-26 milligram tablets prescribed for the treatment of congestive heart failure. 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. Entresto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Zerviate 0.24% ophthalmic drops. The Part D plan denied the request because the drug was not included on the plans formulary and the documentation did not support a formulary exception. 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 Zerviate 0.24% ophthalmic drops have been prescribed for the treatment of open-angle glaucoma with borderline findings, low risk, bilateral (diagnosis code H40.013). However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for 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. Since the drug is not eligible for coverage under Medicare Part D, a formulary exception is not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kesimpta 20 milligram/0.4 milliliter subcutaneous pen prescribed as directed for multiple sclerosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Relevant medical records were requested but not provided. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Kesimpta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Shingrix 50 microgram per 0.5 milliliter reconstituted suspension for intramuscular injection prescribed for shingles prevention. 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 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. Shingrix is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humalog Mix 75/25 Kwikpen prescribed as directed. 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. Humalog Mix is a biological product drug on Tier 3 of the plans formulary. There are no biological product 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 a request for coverage of Lubiprostone 24 microgram capsules 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. The documentation indicates that the enrollee is also taking Linzess, which is a drug in the same therapeutic class as the requested drug. The prescriber has noted at reconsideration that the enrollee uses both Amitiza (Lubiprostone) and Linzess. The prescriber states that the enrollee uses Lubiprostone, one in the morning and one in the evening. If the enrollee does not have a bowel movement in that 24-hour period, then the enrollee will take Linzess the next morning instead of taking the Lubiprostone. However, both of the drugs are in the same pharmacologic class and have the same action. The submitted documentation does not support the medical necessity for the duplicate therapy. 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 Modafinil 200 milligram tablet prescribed for fatigue related to multiple sclerosis. 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 prescriber indicates Modafinil 200 milligram tablets are prescribed to treat fatigue related to multiple sclerosis. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Saxenda 18 milligram per 3 milliliter subcutaneous injection pen prescribed for weight loss due to the presence of obesity. 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 records submitted at the reconsideration level. Drugs when used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose, i.e., morbid obesity) are excluded from the Part D coverage. 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 Rydapt 25 milligram capsules to be used in combination with Azacitidine to treat newly diagnosed acute myeloblastic leukemia. 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug.  Therefore, 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 a request for coverage of Lidocaine adhesive 5% patches. 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 Lidocaine 5% patches have been prescribed for the treatment of a left rotator cuff tear. 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. It should be noted that although the drug is not covered under the enrollees Medicare Part D plan, the enrollee has an enhanced benefit that allows coverage of this drug, and the drug has been approved under this enhanced benefit for one year. A physician reviewed the appeal and determined that the Medicare Part D plan is not required to cover the requested drug; however, coverage is available under the enrollees enhanced benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is an off formulary and tiering exception request for Repatha Sureclick 140 milligram/milliliter  prescribed as directed for familial hypercholesterolemia, atherosclerotic heart disease of native coronary artery without angina pectoris and hyperlipidemia, unspecified. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why all other drugs on the plans formulary would not work for you. In addition, this drug is not included on your plans formulary. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for Lidocaine 5% patch prescribed for back pain related to compression fracture. 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.We requested additional documentation from the prescriber. We asked the prescriber to clarify the diagnosis. Specifically, we requested medical records and a supporting statement. However, we did not receive additional information.The submitted documentation indicates the prescriber ordered Lidocaine 5% patch for pain due to a compression fracture. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of NP Thyroid 90 milligram tablets prescribed for hypothyroidism. The Part D plan denied the request for coverage because the drug was not on the formulary and the documentation did not support a formulary 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. NP Thyroid has not been approved by the Food and Drug Administration for safety and effectiveness. Drugs not approved by the Food and Drug Administration are excluded from Part D coverage. We have determined that the Medicare Part D plan is not required to cover the requested drug. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Remicade 100 milligram vial for intravenous infusion prescribed for the treatment of severe ulcerative colitis. 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. Remicade is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the preferred formulary alternative drug, Humira, would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Austedo 12 milligram tablets prescribed for tardive dyskinesia. 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 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 order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Austedo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Fluticasone Propionate-Salmeterol 250-50 microgram per actuation inhalation powder. The Part D plan denied the request for coverage because the medication was being used for a non-medically accepted indication. 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 diagnosis initially provided by the prescriber to the Part D plan was unspecified dyspnea. 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. At reconsideration, the prescriber has included an additional diagnosis of asthma. However, no medical records have been submitted to validate the additional diagnosis. Therefore, there is insufficient documentation to determine if the requested drug is being prescribed for a medically accepted indication. As such, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Myrbetriq 25 milligram extended release tablets prescribed for overactive bladder. 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 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 indicates the Myrbetriq at issue was prescribed for overactive bladder. The Medicare approved compendia support the use of the drug for this condition. The documentation further indicates the plan approved the Myrbetriq at issue. The plan indicated the enrollee is taking a similar medication in the same class as the Myrbetriq at issue. The provider submitted a statement to indicate the similar medication was tried and failed by the enrollee and will not be used in combination with Myrbetriq.A physician reviewed your appeal and determined that the plan is required to cover Myrbetriq.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ingrezza 40 milligram capsule prescribed for bipolar disorder, current episode depressed, mild or moderate severity, unspecified. The Part D plan denied the request as the drug is not on the plans formulary.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 indicate Ingrezza 40 milligram capsule is prescribed to treat bipolar disorder, current episode depressed, mild or moderate severity, unspecified. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Ingrezza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Aubagio 14 milligram tablets, which have been prescribed for the treatment of relapsing-remitting multiple sclerosis. 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. Aubagio is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Triumeq 600-50-300 milligram tablets. 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. Triumeq is included on Tier 5 of the plans formulary (list of covered drugs). Tier 5 of the formulary is the tier reserved for specialty drugs. The specialty tier is exempt from tiered cost-sharing expectations. Therefore, this drug is not eligible for coverage at a lower-cost tier. A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Invega Sustenna 156 milligrams per 1 milliliter prescribed two milliliters per month for bipolar disorder, current episode manic severe with psychotic features. 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 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 asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this amount of the medication was needed. We did not receive the documentation requested.The doctor prescribed Invega Sustenna 156 milligrams per 1 milliliter to treat the enrollees bipolar disorder. However, the medical records do not support why an exception to the plans quantity limit is medically necessary. A physician reviewed the appeal and determined that the plan is not required to cover the Invega Sustenna, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fasenra 30 milligram capsule prescribed for bronchiectasis and pseudomonas aeruginosa. 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 prescriber indicates that Fasenra is requested to treat severe persistent asthma. However, the medical records do not support a diagnosis of severe asthma with an eosinophilic phenotype. There is no diagnosis found that Medicare approved compendia support as a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover Fasenra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Gralise 300 milligram tablets prescribed for breakthrough migraine pain and restless leg syndrome. 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 submitted documentation indicates the prescriber ordered Gralise for breakthrough migraine pain and restless leg syndrome. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.