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

At issue is a request for coverage of Modafinil 200 milligram tablets prescribed for an unknown condition. The Part D plan denied the request because there was insufficient documentation to determine if the plans prior authorization requirements were met. 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. The available documentation does not include any medical records from the prescriber or the enrollees diagnosis. During this review, a request was submitted to the prescriber to provide the diagnosis, to address the plans prior authorization requirements, and to provide supporting medical records. The prescriber did not respond to the request. Without a diagnosis, it cannot be determined if the drug is being prescribed for a medically accepted indication outlined in the Medicare approved compendia. As such, the drug 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 Sildenafil 20-milligram tablet to treat male erectile dysfunction. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, we determined that the plan is not required to cover the Sildenafil, as it excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Eylea 2 milligram per 0.5 milliliter prefilled syringe for intravitreal injection prescribed for diabetic retinopathy and macular edema of the left eye. 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. Eylea is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient patient specific clinical rationale as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablet prescribed as directed for diarrhea after hemi-colectomy for colon cancer. 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 Xifaxan to treat your diarrhea after hemi-colectomy for colon cancer. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulicity 1.5-milligrams/0.5-milliliter Pen Injector to treat Type 2 diabetes mellitus. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for a tiering exception for Repatha SureClick 140 milligrams per milliliter subcutaneous injection pen prescribed for the treatment of coronary artery disease with hyperlipidemia. 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.Repatha is a biologic drug on Tier 4 of the plans formulary. There are no biologic drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug at a lower cost tier. The drug will continue to be covered at the Tier 4 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humalog Mix 50/50 Kwikpen prescribed as directed for Type 2 diabetes mellitus. 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 Humalog Mix 50/50 Kwikpen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Taltz 80 milligram per milliliter subcutaneous auto injection pen prescribed for the treatment of severe plaque psoriasis. 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. Taltz is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient patient specific clinical rationale as to why all the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Megestrol Acetate 400-milligrams/10-milliliters Oral Suspension to treat cholelithiasis without obstruction and gastroesophageal reflux 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Pramipexole Dihydrochloride ER 3.75 milligram delayed release tablets prescribed for the treatment of Parkinsons disease. 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. Pramipexole Dihydrochloride ER is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient patient specific clinical rationale, supported by medical records, as to why all the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Gilotrif 30 milligram tablets prescribed for the treatment of metastatic lung adenocarcinoma. 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. Gilotrif is included on Tier 5 of the plans formulary (list of covered drugs). Tier 5 of the formulary is the tier reserved for specialty drugs. The specialty tier is exempt from tiered cost-sharing expectations and is not eligible for coverage at a lower-cost tier. 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 Levorphanol Tartrate 2 milligram tablet prescribed for unknown diagnosis. 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 the enrollee requested the Part D plan to provide reimbursement for the Levorphanol Tartrate purchased from a network pharmacy and processed through the enrollee's private insurance plan in error. However, the plan indicates that there is missing information needed to consider the request. The documentation provided includes some of the missing elements with the exception of the prescribing physicians information. The required information should include the prescribing physicians name, address and National Provider Identifier (NPI) number. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information. Please provide this information to the plan for reimbursement consideration.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stendra 200 milligram tablet prescribed for the treatment of erectile dysfunction. The Part D plan denied the enrollees 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. We determined that the plan is not required to cover Stendra for the diagnosis of erectile dysfunction. According to your plans Evidence of Coverage, drugs prescribed to treat sexual/erectile dysfunction are excluded from coverage under Medicare Part D. 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 tiering exception request for Sevelamer Carbonate 800 milligram tablets prescribed to treat disorder of phosphorus metabolism associated with end stage renal 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. Sevelamer Carbonate 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 all generic drugs of the same type on the lower tier of the plans formulary to treat the enrollees condition have been tried and failed, or are contraindicated. Therefore, the tiering exception criteria have not been met. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier. The drug will continue to be covered at the Tier 4 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Esbriet 267 milligram tablets prescribed as directed for interstitial lung disease secondary to 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. The documentation shows your doctor prescribed Esbriet to treat your interstitial lung disease secondary to rheumatoid arthritis. 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 Esbriet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Cyclosporine 100-milligram capsule for interstitial cystitis. 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.Cyclosporine is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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 Xhance 93-micrograms/Actuation Nasal Exhaler Suspension to treat polyp of sinus. The Part D plan denied the request. The requested drug is not on the plans formulary.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.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 records do not support why other drugs on the plans formulary would not work for you.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 Prolia 60 milligram/milliliter syringe 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. Prolia 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 a request for coverage of Vumerity DR 231 milligram delayed release capsules prescribed for the treatment of multiple sclerosis. 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. Vumerity DR is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient patient specific clinical rationale, supported by medical records, as to why all the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acetaminophen 325 millgram tablet for unknown diagnosis. 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 record shows the enrollee received Acetaminophen as a self-administered drug while inpatient in the hospital. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Acetaminophen is an over-the-counter medication. There is no evidence that the enrollee has supplemental coverage for the drug. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alendronate Sodium 70 milligram tablet prescribed for unknown diagnosis. 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 the enrollee requested the plan to provide reimbursement for the Alendonrate Sodium. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the Alendronate Sodium. Please submit your request to Medicare Part A. 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 Absorbic Acid 500 milligram tablet for unknown diagnosis. 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 record shows the enrollee received Absorbic Acid as a self-administered drug while inpatient in the hospital. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Absorbic Acid is an over-the-counter medication. There is no evidence that the enrollee has supplemental coverage for the drug. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin 81 milligram tablet DR for unknown diagnosis. 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 record shows the enrollee received Aspirin as a self-administered drug while inpatient in the hospital. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Aspirin is an over-the-counter medication. There is no evidence that the enrollee has supplemental coverage for the drug. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Culturelle Immunity Support Capsule for unknown diagnosis. 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 record shows the enrollee received Culturelle Immunity Support as a self-administered drug while inpatient in the hospital. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Culturelle Immunity Support is an over-the-counter medication. There is no evidence that the enrollee has supplemental coverage for the drug. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fish Oil 1000 milligram capsule for unknown diagnosis. 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 record shows the enrollee received Fish Oil as a self-administered drug while inpatient in the hospital. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Fish Oil is an over-the-counter medication. There is no evidence that the enrollee has supplemental coverage for the drug. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Furosemide 40 milligram tablet prescribed for unknown diagnosis. 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 the enrollee requested the plan to provide reimbursement for the Furosemide. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the Furosemide. Please submit your request to Medicare Part A. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.