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

At issue is Fosfomycin 3 gram pack prescribed daily for urinary tract 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 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.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 Fosfomycin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Valcyte 450 milligram tablets prescribed to treat human herpesvirus 6 encephalitis and 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 information submitted at the reconsideration level.You requested Valcyte 450 milligram tablets to human herpesvirus 6 encephalitis and infection. The Part D plan denied your request stating that the formulary exception requirements were not met. 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 Valcyte 450 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vancomycin+SYRSPEND SF suspension 50 milligram/milliliter prescribed for c difficile colitis. 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 Vancomycin+SYRSPEND SF suspension. According to Medicare rules, Vancomycin+SYRSPEND SF suspension is a compounded drug that has not been approved by the Food and Drug Administration. 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 Trulicity 0.75 milligram/0.5 milliliter solution 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. Trulicity 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 request for coverage of Corlanor 5 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 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 Corlanor has been prescribed for the treatment of inappropriate sinus tachycardia. 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. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rydapt 25 milligram capsules prescribed as directed for myelodysplastic 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 the doctor prescribed Rydapt to treat myelodysplastic syndrome. The records show the enrollee was initially diagnosed with myelodysplastic syndrome in 2019, and treated with Azacitidine. The enrollee underwent multiple bone marrow biopsies. Initially, the biopsy showed myelodysplastic syndrome refractory anemia with ringed sideroblasts; then, the biopsies showed myelodysplastic syndrome with excess blasts. Most recently, the enrollee was treated with Venetoclax plus Decitabine. After those treatments, the bone marrow biopsy showed treatment effect versus recurrence. However, the enrollee experienced prolonged cytopenias due to treatement with Venetoclax plus Decitabine. Therefore, the physician requested to change the treatment regimen to Rydapt. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Furthermore, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Rydapt.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Emgality 120 milligram per milliliter subcutaneous injection pen prescribed for chronic migraines. 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 Part D plan has prior authorization requirements that must be met before coverage of this medication will be approved. The prescriber has not sufficiently addressed the plans coverage criteria and/or 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 Jardiance 25 milligram tablet prescribed daily for type 2 diabetes mellitus. 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 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.Jardiance 25 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

At issue is a request for coverage of Gralise 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 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 Gralise has been prescribed for unspecified neuropathy of the lower extremity and myalgia. 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. 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 tiering exception request for Galantamine ER 8 milligram capsules for one month, then 16 milligram capsules, which have been prescribed for Alzheimers disease. 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. Galantamine ER is a generic drug on Tier 4 of the plans formulary. The prescriber has not sufficiently addressed why all the drugs on the plans formulary to treat the noted condition have been tried and failed or are contraindicated. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol 0.025 milligrams (two per week) transdermal patches prescribed as directed to treat menopausal syndrome. 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. Estradiol transdermal patch is a generic drug on Tier 3 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

You requested a formulary exception for Cardizem CD 240 milligram capsules. 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 does not contain a supporting statement or medical records. A request for information was sent to the prescriber; however, no further documentation was 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: Unfavorable

You requested Metolazone 2.5 milligram tablet prescribed for edema in an enrollee with severe pulmonary hypertension. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We requested additional information from your prescriber. The documentation shows your doctor prescribed Metolazone 2.5 milligram tablets to treat your edema. Your prescriber also indicates you have severe pulmonary hypertension. 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 Metolazone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuedexta 20 milligram-10 milligram capsules.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 a prescribers statement, the diagnosis related to the requested drug, and medical records or other documentation to show why you need this medication. We did not receive the requested documentation.The appeal is for Nuedexta 20 milligram-10 milligram capsules. However, there were no medical records submitted supporting your condition. The QIC is unable to determine if your condition is a medically accepted indication to support the use of the requested drug.A physician reviewed your appeal and determined that the plan is not required to cover Nuedexta 20 milligram-10 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyproheptadine Hydrochloride  4 milligram tablets prescribed as directed for poor appetite. 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 doctor prescribed Cyproheptadine Hydrochloride for poor appetite. Drugs prescribed to treat anorexia, weight loss, or weight gain 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.We determined that the plan is not required to cover Cyproheptadine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of a Dexcom G6 Sensor continuous glucose monitor prescribed for type 2 diabetes mellitus with diabetic neuropathy. The Part D plan your 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.Continuous glucose monitors are classified by the Food and Drug Administration as medical devices. As such, they do not meet the definition of a Part D drug. Furthermore, continuous glucose monitors are durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as continuous glucose monitors. Coverage under Part D is excluded for any drug or item for which payment would be available under Part B. Therefore, the continuous glucose monitor is not eligible for coverage under Medicare Part D, as it is classified as a medical device and does not meet the definition of a Part D drug. Additionally, being durable medical equipment, coverage for the device is available under Medicare Part B. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rinvoq 15 milligram extended-release 24-hour tablets prescribed to treat Crohns disease. 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 Rinvoq 15 milligram extended-release 24-hour tablets to treat Crohns disease. 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 Rinvoq 15 milligram extended-release 24-hour tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Leflunomide 20 milligram oral tablet. 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. Leflunomide is a generic drug on Tier 3 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat your condition have been tried or deemed contraindicated. 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 Zolpidem Tartrate 10 milligram tablet prescribed daily for anxiety and insomnia. 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 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed, with support of medical records, the issues regarding this high-risk medication, and why alternative safer medications, in the plan's formulary, could not be used. 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 Lidocaine 5% patches prescribed for bilateral osteoarthritis of the knees. 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 supporting statement. A request for information was sent to the prescriber; however, no further documentation was received. The documentation 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: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablets prescribed for anti-coagulation in persistent atrial fibrillation. 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. Eliquis 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

You requested Ascomp-Codeine 50-325-40-30 milligram capsules prescribed as directed for migraine headaches. 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 provided at redetermination shows the doctor prescribed Ascomp-Codeine to treat migraine headaches. However, the Medicare approved compendia do not support the use of this drug for migraine headaches. At reconsideration, the prescriber stated the enrollee also has a diagnosis of tension headaches. However, the medical records submitted by the prescriber did not show a diagnosis of tension headaches. It could not be determined that the requested drug was prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover Ascomp-Codeine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Breztri Aerosphere 160-9-4.8 HFA aerosol with adapter prescribed for chronic obstructive pulmonary disease. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation. 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, we did not receive medical records to 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 Breztri Aerosphere.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Ajovy 225 milligram/1.5 milliliter auto injector 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.Ajovy is a non-formulary brand drug. Non-formulary drugs are 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.