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

At issue is Pregabalin 75-milligram capsule to treat non-pressure chronic ulcer of unspecified part of left lower leg with fat layer exposed. 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.At reconsideration the diagnoses of fibromyalgia in association with venous ulcer and lipodermatosclerosis with chronic neuropathic pain was given. The provided medical records dated 8/6/2021 do not support the diagnosis of fibromyalgia.   The provided records support the diagnosis of , 'early phase lipodermatosclerosis with chronic neuropathic pain.'   Also note that the prescriber was asked by the plan if the enrollee had fibromyalgia or diabetic peripheral neuropathy.  The prescriber answered, 'No.'  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 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 Travoprost 0.004% eye drop. The Part D plan denied the 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. We asked the prescriber to send us information about the enrollees condition. We also asked for medical records or other documentation to show why the medication is needed. Specifically, we asked for records to show why similar medications on the lower tiers would not work. We received a prescribers statement and included it in our review.Travoprost is a generic drug on Tier 3 of the plans formulary. The prescriber did not provide medical records to support why the drugs available on the lower tiers of the plans formulary would not work. Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prevymis 480-milligram tablet to treat cytomegaloviral disease, unspecified in the setting of lung transplant status. 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 Prevymis to treat your cytomegaloviral disease, unspecified. However, the Medicare approved compendia do not support the use of this drug for your condition. 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 Tadalafil 40 milligram tablets prescribed for pulmonary hypertension, multifactorial, World Health Organization Group 3 and 4. 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 prescriber submitted a statement to indicate the enrollee has a diagnosis of idiopathic pulmonary hypertension, World Health Organization Group I. However, the medical records submitted indicate the enrollees diagnosis is pulmonary hypertension, multifactorial, World Health Organization Group 3 and 4. The Medicare approved compendia do not support the use of the drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lynparza 150 milligram tablet prescribed for malignant neoplasm of submandibular gland, recurrent and metastatic to lung with recurrent pleural effusion. 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 Lynparza was prescribed to treat malignant neoplasm of submandibular gland, recurrent and metastatic to lung with recurrent pleural effusion. 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 Lynparza.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Repatha Sureclick 140 milligram/milliliter subcutaneous pen injector prescribed as directed for atherosclerotic heart disease of native coronary artery without angina. 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 Repatha Sureclick to treat your atherosclerotic heart disease of native coronary artery without angina. 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 Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Verzenio 150 milligram tablet prescribed for invasive lobular carcinoma of the breast. 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 show the enrollee has metastatic hormone positive breast cancer and was initially started on Ibrance/Anastrazole. An imaging study in June 2021 showed new leptomeningeal disease for which the enrollee received radiation and otherwise, imaging showed stable disease. It was discussed if the enrollee should stay on the current treatment as she had no symptoms of leptomeningeal disease and no other progression. The decision was to change to Verzenio/Faslodex as Verzenio has better blood brain barrier penetration. However, Medicare approved compendia and the Food and Drug Administration criteria do not support the use of this drug for enrollees that were on a CDK 4/6 inhibitor previously. There are no studies to support using Verzenio after Ibrance in Medicare supported journals.A physician reviewed your appeal and determined that the plan is not required to cover Verzenio.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Prednisolone-Gatifloxacin-Bromfenac Sodium Ophthalmic suspension 5 milliliter compounded drug prescribed for treatment after cataract surgery.   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 Prednisolone-Gatifloxacin-Bromfenac Sodium Ophthalmic suspension is a compounded drug and each ingredient is reviewed individually. The National Drug Codes, 38779-0152-09 for Prednisolone, 12344-0161-01 for Gatifloxacin, and 40016-0004-01 for Bromfenac Sodium, provided by the enrollee are not listed with the Food and Drug Administration as valid codes. Therefore, we determined the plan is not required to cover the compounded drug or provide reimbursement. 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 Livalo 4 milligram tablets prescribed to treat an enrollee with coronary artery disease with hyperlipidemia. The Part D plan denied the appeal 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 prescriber indicates that one of the plans alternative formulary drugs was tried and failed or could cause harm. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the records do not support why all 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 Livalo 4 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 20 milligram tablets. The Part D plan denied the appeal request for a tiering 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.Xarelto 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.. Therefore, this drug is not eligible for a tiering exception.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 Azathioprine 50 milligram tablet prescribed for Sjogrens syndrome with leukocytoclastic vasculitis. 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 prescriber indicates that Azathioprine is prescribed to treat Sjogrens syndrome with leukocytoclastic. 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 Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 100 milligram tablets prescribed for migraine without aura, not intractable, without status migrainosus. 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 requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the plans formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.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 Ubrelvy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira Pen 40 milligram/0.4 milliliter injection prescribed for seborrheic dermatitis of scalp and nummular eczema with psoriasis. 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 documentation shows the prescriber ordered Humira for seborrheic dermatitis of scalp and nummular eczema with psoriasis. However, the Medicare approved compendia do not support the use of this biologic for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brimonidine 0.15% Ophthalmic Eye Drops to treat an unknown condition. 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.We asked your prescriber to send us a prescriber statement, to clarify the medical history, to address the non-formulary exception coverage criteria, and to provide medical records. We received the prescriber statement and included it in our review. However, the medical records were not submitted.At reconsideration, the diagnosis of bilateral glaucoma was given. Brimonidine 0.15% ophthalmic drops is not on the plan's formulary. The prescriber states that the formulary alternative Brimonidine 0.2% ophthalmic drops  would be appropriate to treat the enrollee's condition.  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.A physician reviewed the appeal and determined that the requested drug, Brimonidine 0.15% ophthalmic drops, is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tasigna 150 milligram capsules prescribed as directed for an unspecified illness. 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 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.The documentation shows your doctor prescribed Tasigna. However, documentation was not received to determine if it was prescribed for a medially accepted indication. Therefore, it could not be determined if the Medicare approved compendia supported the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Tasigna.
Appeal type: Prescription Drug
Decision: Favorable

At issue is reimbursement for Shingrix vial kit. The Part D did not make a timely decision for the Shingrix vial kit received on June 10, 2021.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 receipt is provided that supports a total of $291.00 was paid by the enrollee for a shingles vaccine and the administration for the date of June 10, 2021. The documentation is sufficient to support the medical necessity of the vaccine and reimbursement for the shingles vaccine.  A physician reviewed your appeal and determined that the plan is required to reimburse the amount of the Shingrix vial kit and administration fee.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets prescribed for unspecified disease of the intestine. 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 documentation shows the prescriber originally ordered Xifaxan for unspecified disease of the intestine. On appeal, the prescriber indicated the enrollee has a diagnosis of small intestinal bacterial overgrowth. There were no medical records submitted to support a chance in diagnosis. The Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Sodium Bicarbonate 8.4% Solution to treat gastroesophageal reflux disease and Rett's 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.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.Our physician reviewer's opinion is that non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Simbrinza 1%-0.2% ophthalmic drops suspension.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.Simbrinza 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. Therefore, this drug is not eligible for a tiering exception.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 Cyanocobalamin 1000 microgram/milligram. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. The drug requested is a prescription vitamin. Vitamins and minerals are excluded from coverage under Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Cyanocobalamin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 1.5 milligram capsules prescribed for major depressive disorder and generalized anxiety disorder. 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 documentation shows the prescriber originally ordered Vraylar for major depressive disorder and generalized anxiety disorder. The Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Donnatal 16.2milligram tablets prescribed as directed. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.We determined that the plan is not required to cover Donnatal because the drug has not been approved by the Food and Drug Administration for the treatment of any condition. Drugs that have not been approved by the Food and Drug Administration 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

You requested prior authorization for Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed as directed for chronic spasm. 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 Cyclobenzaprine Hydrochloride to treat your chronic spasm. 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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prior authorization for Rituxan 500 milligram/50 milliliter prescribed as directed for chronic kidney disease and nephrotic 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. The documentation shows your doctor prescribed Rituxan to treat your chronic kidney disease and nephrotic syndrome. 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 Rituxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zoledronic Acid 5 milligram/100 milliliter injection prescribed as directed for age-related osteoporosis without current pathological fracture. 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 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 Zoledronic Acid.