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

At issue is a tiering exception request for Entresto 97-103 milligram tablets to treat your condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Entresto 97-103 milligrams is a brand drug on Tier 2 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Austedo 12 milligram tablets to treat tardive dyskinesia. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any 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/or the coverage criteria are not satisfied by the provided medical records.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 Armour Thyroid 90 milligrams to treat hypothyroidism. The Part D plan denied your request for a tiering exception. 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. Non- Food and Drug Administration (FDA) approved drugs are excluded from Medicare Part D coverage.  Per the Medicare approved compendia, This drug has not been found by the US FDA to be safe and effective, and the drug product labeling has not been approved by the FDA. Therefore, the requested drug is excluded from coverage. 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 Methylphenidate 5 milligrams prescribed two times daily for unknown condition. The Part D plan denied your request for unknown reasons. 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. The case file was requested but not received.A physician reviewed your appeal and determined that the plan is not required to cover the Methylphenidate. There is insufficient documentation to determine if the medicine is medically necessary.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Freestyle libre 14 day sensor prescribed for reactive hypoglycemia. The Part D plan denied coverage because Medicare only covers the requested item when the enrollee is using insulin injections three or more times daily, or a Medicare covered continuous subcutaneous insulin infusion pump. We received a reconsideration request. We performed and 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 Part D plan is not required to cover Freestyle libre 14 day sensor because it is not considered a medical supply directly associated with the injection of insulin. The record shows Medicare Part B denied coverage because the enrollee does not have a diagnosis of diabetes and is not being treated with insulin injections, or uses an insulin infusion pump. 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 Orencia Clickjet 125 milligram/milliliter prescribed for rheumatoid arthritis. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 physicians statement was submitted and stated you had tried Rituxan, Enbrel, Methotrexate, and Humira. Medicare approved compendia supports the use of the requested drug for your condition. However, the records do not show why you cannot take other drugs on your plans formulary for your condition. These may include Kevzara and Rinvoq.A physician reviewed your appeal and determined that the plan is not required to cover Orencia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dexilant 60 milligram capsules prescribed daily for gastroesophageal reflux disease with esophagitis. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed and 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. Dexilant 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 cover Dexilant because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rinvoq Extended Release 15-milligram tablet prescribed for rheumatoid arthritis. Your Part D plan denied the drug because the guideline rules were not met. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The records show your doctor prescribed a Rinvoq Extended Release to treat your rheumatoid arthritis. However, the records do not show that you have met the prior authorization conditions of coverage. Also note that medical records were requested and were not provided.  A physician reviewed your appeal and determined that the plan is not required to cover Rinvoq Extended Release because the conditions of coverage have not been met per Medicare rules.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mycophenolate Mofetil 250 milligram three capsules twice a day prescribed for kidney transplant rejection prophylaxis. The Part D Plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We determined that the drug is not eligible for Part B coverage. The transplant was not covered by Medicare. Therefore, the drug can be considered for payment under the Part D benefit. The doctor prescribed Mycophenolate Mofetil to treat the enrollees condition. The Medicare approved compendia supports the use of this formulary drug for your condition.A physician reviewed your appeal and determined that the plan is required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tacrolimus 1 milligram, four capsules in morning and three capsules in evening prescribed for kidney transplant rejection prophylaxis. The Part D Plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We determined that the drug is not eligible for Part B coverage. The transplant was not covered by Medicare. Therefore, the drug can be considered for payment under the Part D benefit. The doctor prescribed Tacrolimus 1 milligram to treat the enrollees condition. The Medicare approved compendia supports the use of this formulary drug for your condition.A physician reviewed your appeal and determined that the plan is required to cover Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Imatinib Mesylate 400 milligram tablet prescribed daily for metastatic prostate cancer with tyrosine-protein kinase KIT, guanine nucleotide-binding protein, and phosphatase and tensin homolog gene mutations. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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. The records show your physician prescribed Imatinib Mesylate to treat your metastatic prostate cancer. However, the Medicare approved compendia and Medicare approved journals do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Imatinib Mesylate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz XR tablets. This case was an auto-forward coverage determination.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. This drug is at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram/milliliter auto injector prescribed for pure hypercholesterolemia. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited 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. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.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 Fondaparinux sodium subcutaneous solution 10 milligrams/0.8 milliliter. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. We received an expedited 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. This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Fondaparinux sodium. A tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Propafenone Hydrochloride 225 milligrams prescribed for paroxysmal atrial fibrillation. The Part D Plan denied your request for a tiering exception because the submitted documentation did not explain why the plans drugs in lower tiers would not work just as well. We received an expedited reconsideration request. Propafenone Hydrochloride is a generic drug on Tier 3 of the plans formulary. Your doctor submitted a statement. However, your doctor did not address why all alternative lower-tier medication on the plans formulary would not work for you. All generic drugs on lower tiers have not been tried. 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 Doxorubicin HCl Liposome. We received an expedited 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. The submitted documentation does not contain medical records to indicate the diagnosis for the drug at issue. A request for information was submitted to the prescriber. No medical records were submitted for review. As it cannot be determined 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

At issue is Lorazepam1 milligram tablets prescribed. The Part D plan denied coverage because insufficient documentation was provided. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We requested a prescriber statement with the enrollees condition and medical records to support the plans prior authorization requirements. A prescriber statement and medical records were not received. The plan includes requirements for high risk medications. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Lorazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent patch prescribed for pain management for a history of bilateral total knee replacements due to patella fractures. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received an expedited 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. We also researched Medicare systems and reviewed the enrollment data available. 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 drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5 percent patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% patch. The Part D plan denied coverage because you did not have a medically accepted indication. We received an expedited reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The records indicate that the enrollee has chronic pain due to M54.2, Cervicalgia and M54.6, Pain in thoracic spine with thoracic spondylosis with mild and moderate bulging discs. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Epolamine 1.3% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Incruse Ellipta 62.5 microgram powder prescribed daily for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. We received an expedited 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.Incruse Ellipta 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 Novolog 100 units/milliliter FlexPens for subcutaneous injection prescribed as directed for type II diabetes mellitus. The Part D plan denied your request because the drug was requested at a quantity of 225 milliliters per 88 days; the plan stated the prescriber did not provide a medical reason for this amount of medication. 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. The documentation shows the doctor prescribed Novolog to treat type II diabetes mellitus. The Medicare approved compendia support the use of this drug for the enrollees condition. The prescriber indicates the enrollee takes 31 units of Novolog per day, and therefore requires 930 units of Novolog per month. This equates to 27 milliliters of Novolog 100 units/milliliter FlexPen insulin per 88 days. This drug is included on the plans formulary and the plan has not imposed prior authorization criteria for this drug. Therefore, coverage can be allowed for the medically necessary quantity of 27 milliliters per 88 days. A physician reviewed your appeal and determined that the plan is required to cover 27 milliliters of Novolog 100 units/milliliter FlexPen insulin per 88 days.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine HCl 2 milligram sublingual tablet prescribed for the enrollees opioid dependence. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of opioid dependence. However, the enrollee does not satisfy 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

You requested Guanfacine ER 1 milligram tablets prescribed twice daily. We received an expedited 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. The submitted documentation does not indicate the condition the drug was prescribed for. There were no records submitted. A supporting statement indicates the enrollee has diagnoses of schizoaffective disorder, intellectual disabilities, and bipolar disorder. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined 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 coverage for Juxtapid 5 milligram capsules prescribed for the treatment of hyperlipidemia with coronary artery disease and peripheral vascular disease. The Part D plan denied the request stating that the medication was prescribed for a non-medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber statement submitted at reconsideration includes an additional diagnosis of homozygous familial hypercholesterolemia. However, the submitted medical records indicate that the enrollee probably has homozygous familial hypercholesterolemia but has never been formally tested. Therefore, the diagnosis of homozygous familial hypercholesterolemia cannot be validated by the submitted documentation.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 of hyperlipidemia with coronary artery disease and peripheral vascular disease. 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 Juxtapid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cresemba 186 milligram capsules prescribed for blastomycosis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. The medical records show the doctor prescribed Cresemba for blastomycosis. However, 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 Cresemba.