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

At issue is Xarelto 20 milligram tablets 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. Xarelto 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 Timolol Maleate 0.5% ophthalmic gel forming solution prescribed for bilateral open-angle glaucoma. 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.Timolol Maleate 0.5% ophthalmic gel forming solution is classified as a brand drug and it is 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 your appeal and determined that the plan is not required to cover the drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

Shingrix Vial Kit Injection was requested. The Part D plan denied your 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 information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis, prescriber statement, and to provide supporting medical records. A reply from the prescriber was not received. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tretinoin 0.025% gel. 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.No medical records were received to support a diagnosis. A request for information was sent to your physician. Medical records were not received. 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: Favorable

You requested Paroxetine Mesylate 7.5 milligram capsules prescribed for mild depression as a result of menopausal hot flashes. 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 Paroxetine Mesylate for mild depression as a result of menopausal hot flashes. Documentation submitted includes documentation of daily hot flashes that disturb sleep. The Medicare approved compendia support the use of the drug at issue for your conditions. The drug was prescribed for a medically accepted indication and coverage can be allowed.A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Emgality 120-milligrams/milliliter Solution Prefilled Syringe to treat migraine headaches. 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 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

At issue is a prior authorization request for Prolia 60 milligram/milliliter syringe prescribed for osteoporosis. The Part D plan denied coverage.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 documentation on hand does not include a physician supporting statement. A request for information was sent to the prescribing physician. No further documentation was received. The documentation on hand does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Fluocinonide 0.1% cream prescribed daily for diabetic polyneuropathy. 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 documentation shows your doctor prescribed Fluocinonide to treat your diabetic polyneuropathy. 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 Fluocinonide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Anucort  HC 25 milligram suppositories prescribed for an unknown diagnosis. 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 determined that the plan is not required to cover the Anucort. According to Medicare rules, Anucort has not been found by the Food and Drug Administration to be safe and effective; and the drug product label has not been approved.  Therefore, the drug is excluded from coverage under Medicare Part D. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Enbrel 50-milligrams/milliliter to treat systemic lupus erythematosus, unspecified. 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

At issue is a prior authorization request for Daliresp 500 microgram tablets prescribed for centrilobular emphysema. The Part D plan denied coverage.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 documentation on hand did not include a physician supporting statement or medical records. A request for information was sent to the prescriber. Medical records and a supporting statement were submitted. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Modafinil 20 milligram tablets prescribed daily for circadian rhythm sleep disorder, shift work type and hypersomnia due to medical condition. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Modafinil to treat your obstructive sleep apnea confirmed by polysomnography. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Modafinil is indicated to improve wakefulness in patients with excessive sleepiness associated with obstructive sleep apnea. Your doctor submitted a polysomnography confirming a diagnosis of obstructive sleep apnea.A physician reviewed your appeal and determined that the plan is required to cover Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Clorazepate Dipotassium 7.5 milligram tablets 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.Clorazepate Dipotassium is a generic drug on Tier 4 of the plans formulary. The records submitted indicate you were prescribed the drug at issue for vertigo. The Medicare approved compendia do not support the use of the drug at issue for your condition. As the drug was not prescribed for a medically accepted indication, the 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 Vraylar 20 milligram oral capsule prescribed daily for unspecified psychosis not due to a substance or known physiological condition and psychotic disorder with hallucinations. 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 documentation shows your doctor prescribed Vraylar to treat psychosis and psychotic disorder with hallucinations. However, the Medicare approved compendia do not support the use of this drug for your condition. As such, 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 Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira Pen-PSOR/UVEIT Starter Pen-Injector Kit to treat superficial pyoderma gangrenosum and suppurative dermatitis. 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 diagnoses are off-label uses. 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Phospha 250 Neutral 155/852/130 milligram tablet prescribed for an unknown diagnosis. 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 determined that the plan is not required to cover the Phospha 250 Neutral. According to Medicare rules, Phospha 250 Neutral has not been found by the Food and Drug Administration to be safe and effective; and the drug product label has not been approved.  Therefore, the drug is excluded from coverage under Medicare Part D. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate Nebulizer Solution 2.5milligram/3 milliliter. 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 documents submitted indicate the enrollee is not in a long-term care facility or intermediate care facility. The medication will be used in the home and is not covered under Part D drug benefits. However, this drug may be covered under Medicare Part B benefits. We determined that the plan is not required to cover Albuterol Sulfate Nebulizer Solution.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Arikayce 590 milligrams/8.4 milliliters prescribed as directed for mycobacterium avium-intracellulare infection. 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.Your medical records show your doctor prescribed Arikayce to treat your mycobacterium avium-intracellulare infection. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation includes documentation of liver function test abnormalities. Although negative cultures have been obtained, antibiotics previously used must be discontinued. The documentation submitted does not show the enrollee has satisfied the plan's coverage criteria indicated by adverse effects of other drugs.A physician reviewed your appeal and determined that the plan is required to cover Arikayce.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Dupixent 300 milligram/2 milliliter pen injector prescribed for bullous pemphigoid. The Part D plan denied your request as the diagnosis submitted was not a medically accepted indication. 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 Medicare approved compendia indicate Dupixent carries an orphan drug designation for the treatment of bullous pemphigoid. However, Dupixent is not on the plans formulary. A request for a supporting statement was sent to the prescriber. No further documentation was received. The documentation on hand does not support that formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Favorable

You requested Lorazepam 0.5 milligram tablets prescribed as 1 tablet 2 times a day as needed with a quantity of 14 tablets for 7 days for unspecified abdominal pain. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber indicates they prescribed Lorazepam 0.5 5 milligram tablets to treat generalized anxiety disorder. The prescriber indicates enrollee is on concurrent opioid medications for severe chronic abdominal pain and came to the practice on both medications and the enrollee has been on the drug for over 2 decades and continues to follow with a therapist. Medicare approved compendia support the use of this drug for this condition. The plans prior authorization criteria is for new starts only.  A physician reviewed your appeal and determined that the plan is required to cover Lorazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ingrezza 40 milligram capsules prescribed daily for tardive dyskinesia. 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. The records indicate that you tried Austedo 9 milligrams twice daily. The notes do not indicate a contraindication to the drug or trying the maximum dosage. 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 Ingrezza.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent topical patch prescribed as directed for thoracic-12 vertebral fracture of the spine. 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 documentation shows your doctor prescribed Lidocaine 5 percent topical patch to treat your thoracic-12 vertebral fracture of the spine. 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 Lidocaine 5 percent topical patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipratropium-Albuterol 0.5-3milligram/3 Ampule prescribed for chronic obstructive pulmonary disease and shortness of breath. 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 records indicate the drug will be used in a nebulizer at home. This drug is not eligible for coverage under Part D drug benefits. However, this drug may be covered under Medicare Part B benefits. We determined that the plan is not required to cover Ipratropium-Albuterol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram/milliliter pen injector 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. Repatha Sureclick 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: Favorable

You requested Cabometyx 60 milligram tablets prescribed as directed for advanced hepatocellular carcinoma.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We received the documentation and included it in our review.The documentation shows the doctor prescribed Cabometyx as a single agent to treat advanced hepatocellular carcinoma. The record shows the enrollee experienced disease progression despite prior treatment with a combination of Tecentriq and Avastin. The medical records also support that the enrollee has a Child-Pugh score of Class A. The National Comprehensive Cancer Network guidelines, a Medicare approved compendium, support the use of this drug for the enrollees condition. The National Comprehensive Cancer Network guidelines provide a Category 1 recommendation that Cabometyx can be given as subsequent treatment as a single agent for progressive disease in patients (Child-Pugh Class A only) who have unresectable disease and metastatic disease'. The enrollee has been prescribed Cabometyx for a medically accepted indication. The plans prior authorization criteria for prior treatment with Sorafenib has not been satisfied. However, the enrollees prior treatment regimen of Tecentriq and Avastin is supported by the National Comprehensive Cancer Network guidelines. We find that an exception to the plans prior authorization criteria is supported by a Medicare approved compendium for this enrollee. A physician reviewed your appeal and determined that the plan is required to cover Cabometyx.