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

At issue is Cyclobenzaprine HCL 5 milligram tablet prescribed for restless leg syndrome and chronic knee 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 documentation shows Cyclobenzaprine HCL was prescribed to treat the Enrollees restless leg syndrome and chronic knee pain. However, the Medicare approved compendia do not support the use of this drug for your conditions. A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 milligram oral tablet prescribed daily. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. Jardiance is a brand drug on Tier 2 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 Chantix 1 milligram tablet 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. Chantix is a brand drug on Tier 4 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 Xtampza ER 9 milligram capsules prescribed as directed. The Part D plan denied the enrollees request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read the enrollees case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Xtampza ER 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 the enrollees 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 Sildenafil Citrate 20 milligram tablet prescribed for erectile dysfunction due to malignant neoplasm of the prostate and prostatectomy. The Part D plan denied the request. We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review including the case file from the plan and any information submitted at the reconsideration level. The record shows that the doctor prescribed Sildenafil Citrate to treat sexual or erectile dysfunction. We determined that the plan is not required to cover the Sildenafil Citrate . Medicare excludes certain drugs from Part D coverage. Sildenafil Citrate is an excluded drug when used to treat sexual or erectile dysfunction; or to treat a condition other than sexual or erectile dysfunction for which the drug has not been approved by the Food and  Drug Administration. The record does not indicate that the plan provides supplemental coverage for Sildenafil Citrate . Therefore, the plan is not required to cover it. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sildenafil 20 milligram tablets. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Sildenafil has been prescribed for pulmonary hypertension classified as World Health Organization Group 2  and Group 3.  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 Diclofenac Sodium 3% gel prescribed for right shoulder 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 documentation shows Diclofenac Sodium was prescribed to treat right shoulder pain. However, the Medicare approved compendia do not support the use of this drug for the Enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Budesonide 0.5 milligram per 2 milliliter nebulizer ampules prescribed for asthma. 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 documentation indicates that the Budesonide is administered via nebulizer. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as a nebulizers. Payment will also be made under Medicare Part B for the drugs that are put into the nebulizer. Coverage under Part D is excluded for any drug for which payment would be available under Part B. Subsequently, a tiering exception cannot be granted by the Part D plan for a drug that is covered by Medicare Part B. 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 a request for coverage of Prevymis 480 milligram tablets. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Prevymis has been prescribed prophylactically to prevent further cytomegalovirus infection in an enrollee who has a history of cardiac transplant and was recently hospitalized with cytomegalovirus viremia, enteritis and pneumonitis. However, as outlined in the Medicare approved compendium, American Hospital Formulary Service Drug Information (AHFS-DI), the safety and efficacy of Prevymis for prophylaxis to prevent cytomegalovirus infection in solid organ transplant recipients has not been established. Therefore, the drug is being used 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 Renacidin 1980.6-59.4-98.0 milligrams per 30 milliliters prescribed for sludge in catheter due to neurogenic bladder secondary to multiple sclerosis The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The record shows Renacidin is being used to irrigate the enrollees pubic catheter twice daily. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Renacidin. Please submit your request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Gammagard 10% (20 gram per 200 milliliter) solution for intravenous infusion. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The submitted medical records indicate that Gammagard is being prescribed for the treatment of common variable immunodeficiency. While common variable immunodeficiency is a medically accepted indication for the use of Gammagard outlined in the Medicare approved compendia, the administration of Gammagard in the treatment of common variable immunodeficiency is covered under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law. As such, our decision is that the Part D plan is not required to cover the Gammagard.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Diclofenac Sodium 1% gel. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Diclofenac Sodium gel has been prescribed for the treatment of pain in both shoulders, unspecified osteoarthritis, and unspecified other chronic pain. 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 conditions. Therefore, the drug is being prescribed for non-medically accepted indications 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 Celecoxib 200 milligram capsules prescribed for lower back pain. 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.  Relevant medical records were requested.  No medical records were provided.Celecoxib is a generic drug on Tier 4 of the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the generic drugs of the same type on the lower tiers of 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 a request for coverage of Sivextro 200 milligram tablets. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Sivextro have been prescribed for the treatment of central nervous system and cutaneous nocardiosis. 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 Epidiolex 100 milligrams per milliliter prescribed for Tourette's syndrome. 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 doctor prescribed Epidiolex to treat the enrollees Tourette's syndrome. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Epidiolex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of non-formulary Micafungin 50 milligram vials for intravenous infusion. The Part D plan denied the request because there was insufficient documentation to determine if the drug would be covered under Medicare Part D or to determine if a formulary exception could be granted. 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 medical records indicate that Micafungin has been prescribed for the treatment of fungemia/unspecified mycosis. 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 request for coverage of Briviact 75 milligram tablets prescribed for intractable juvenile myoclonic epilepsy. 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 plan has a step therapy requirement for Briviact. The prescriber has not indicated that all alternatives required by the plan have been tried and failed, or why the plans required step therapy drugs would likely not be as effective as the requested drug.  Our physician reviewer's opinion is that neither step therapy nor step therapy exception criteria are met. 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 Trelegy Ellipta 200-62.5-25 micrograms per inhalation aerosol powder prescribed daily for moderate persistant asthma with acute exacerbation. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. 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. A physician reviewed your appeal and determined that the plan is not required to cover Trelegy Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clobazam 10 milligram tablets prescribed as directed for intractable localization-related epilepsy. 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 the enrollees 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 enrollees doctor prescribed Clobazam to treat your intractable localization-related epilepsy. 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 Clobazam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Auryxia 1gram tablets with 210 mg of elemental iron per tablet. 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 Auryxia is being prescribed as iron replacement therapy for the treatment of iron deficiency anemia. However, prescription vitamin and mineral products are excluded from coverage under Medicare Part D. Therefore, the Auryxia is not eligible for coverage under Medicare Part D. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz 5 milligram tablets prescribed as directed for rheumatoid arthritis. 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 Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Airduo Respiclick 113-114 microgram actuator aerosol powder prescribed for mild persistent asthma. The case was auto-forwarded by the plan.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 to support a covered diagnosis. 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

At issue is a request for coverage of Tobramycin 300 milligram per 5 milliliter nebulizer solution, 140 milliliters for a 14-day supply. The Part D plan denied the request for coverage because the amount requested exceeded the plans quantity limits. Additionally, the medication was being used for a non-medically accepted indication.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that nebulized Tobramycin has been prescribed for the treatment of pseudomonas in an enrollee with a history of tracheitis and mediastinitis who does not have bronchiectasis.  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. Since the drug is not eligible for coverage under Medicare Part D, the plans quantity limits are not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover the requested medication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine HCL 8 milligram tablet prescribed for moderate to severe 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. 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. The documentation shows your doctor prescribed Buprenorphine HCL to treat moderate to severe pain. 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 Buprenorphine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Gammaked 10 gram/100 milliliter injection prescribed for myasthenia gravis without acute exacerbation. 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. The medical records show Gammaked was prescribed to treat myasthenia gravis without acute exacerbation. The plan has prior authorization requirements for this drug that must be met before they will cover Gammaked. 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 Gammaked. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.