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

You requested Acetaminophen 325 milligram tablets prescribed as directed. The Part D plan denied your request because Medicare has excluded over-the-counter drug products from Part D coverage. We received an auto-forwarded 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 determined that the plan is not required to the Acetaminophen because it is an over-the-counter drug. Nonprescription, or over-the-counter drugs, 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 reimbursement cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atenolol 50 milligrams provided in the emergency department. The case was auto-forwarded by the plan. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This medication is excluded from coverage under Medicare Part D as it is not a Part D drug in the setting where it was provided. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to reimburse payment for the Atenolol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carbidopa and Levodopa provided in the emergency department. The case was auto-forwarded by the plan. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This medication is excluded from coverage under Medicare Part D as it is not a Part D drug in the setting where it was provided. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to reimburse payment for the Carbidopa and Levodopa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Citalopram 20 milligrams provided in the emergency department. The case was auto-forwarded by the plan. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This medication is excluded from coverage under Medicare Part D as it is not a Part D drug in the setting where it was provided. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to reimburse payment for the Citalopram.
Appeal type: Prescription Drug
Decision: Unfavorable

 At issue is Quetiapine 25 milligrams provided in the emergency department. The case was auto-forwarded by the plan. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This medication is excluded from coverage under Medicare Part D as it is not a Part D drug in the setting where it was provided. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to reimburse payment for the Quetiapine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Warfarin 5 milligrams provided in the emergency department. The case was auto-forwarded by the plan. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This medication is excluded from coverage under Medicare Part D as it is not a Part D drug in the setting where it was provided. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to reimburse payment for the Warfarin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Vimpat 200 milligram tablet to treat epilepsy.  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.Vimpat 200 milligram tablet is a brand drug on Tier 4 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 Estrogen-Methyltestos F.S. tablet. 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 plan denied the request for coverage of the requested drug because your plan's Medicare Part D drug plan cannot cover drugs classified as being part of the Food and Drug Administration (FDA)'s Drug Efficacy Study Implementation (DESI) program. These drugs are considered to be Less than Effective (LTE) per Food and Drug Administration review.A physician reviewed your appeal and determined that the plan is not required to cover Estrogen-Methyltestos F.S. tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Afinitor prescribed as directed for ovarian cancer. You requested that the plan provide coverage for a drug that was not prescribed for a medically accepted indication. The plan did not make a decision within the required timeframe. We received an auto-forwarded reconsideration request from 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 medical records show the doctor prescribed Afinitor to treat recurrent high-grade serous ovarian cancer. The physician also states phosphatase and tensin homolog (PTEN) mutation was noted on molecular testing. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  A physician reviewed your appeal and determined that the plan is not required to cover Afinitor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 2.5 milligram tablet for the prophylaxis of embolism with atrial fibrillation. 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.Eliquis 2.5 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 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 Tysabri 300 milligrams/15 milliliters, intravenous prescribed once every four weeks for multiple sclerosis. 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. We also researched Medicare systems and reviewed the enrollment data available.Your physician submitted a prescribers statement and records. The records show that the physician prescribed Tysabri to treat your multiple sclerosis. The plan formulary includes other drugs that could be used to treat your condition. However, the records do not show all alternative drugs on the plan formulary have been tried for your condition and or why they cannot be used to treat your condition.  A physician reviewed your appeal and determined that the plan is not required to cover Tysabri. This 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

You requested Capecitabine 500 milligrams prescribed 90 in 21 days for malignant neoplasm of the ascending colon. 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.The record shows Capecitabine was ordered for the enrollees condition. However, this drug is eligible for coverage under Medicare Part B. Oral anti-cancer drugs to treat cancer may be covered by Part B.We determined that the plan is not required to cover Capecitabine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atovaquone 750 milligrams/5 milliliters suspension prescribed for antifungal prophylaxis. 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. Atovaquone is a brand drug on Tier 5, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the specialty tier from the tiering exception process. 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 Atovaquone. A tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dalfampridine ER 10 milligram tablet prescribed twice daily for late onset cerebellar ataxia. The Part D plan denied your request because drug 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. Your medical records show your doctor prescribed Dalfampridine ER to treat your cerebellar ataxia. 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 Dalfampridine ER. The drug was not prescribed for a medically accepted indication. This 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 Performist 20 micrograms/2 milliliter inhalation nebulizer solution for symptoms related to chronic obstructive respiratory disease. 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 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 also researched Medicare systems and reviewed the enrollment data available.The inhalation solution is subject to Part B and is not eligible to be covered under the Medicare Part D prescription drug benefit. We have determined that the plan is not required to cover the inhalation nebulizer solution.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Dexamethasone 6 milligram tablets prescribed for pneumonia due to Covid-19. The Part D plan denied the request because the Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. The record shows you were prescribed the drug at issue for pneumonia due to Covid-19. Due to the pandemic, you purchased the drug at the hospital pharmacy, which was out-of-network. Due to the quarantine situation, the enrollee was not able to purchase the drug at a retail pharmacy. We determined that the plan is required to reimburse you for the drug at issue. The Medicare rules above have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Milrinone for administration by intravenous infusion pump at home.  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 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.Based on the information provided, we determined the drug would be eligible for coverage under Part B under Medicare rules.  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 Megestrol Acetate Suspension 625 milligrams/5 milliliters prescribed for malignant melanoma of the skin. The Part D plan denied your request because drug was not prescribed for 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. Your medical records show your doctor prescribed Megestrol Acetate Suspension to treat your anorexia. However, the Medicare approved compendia do not support the use of this drug for your condition.  There must be records to support an FDA or non-FDA medically accepted indication.  Please note, as previously indicated by your plan, Megestrol Acetate Suspension is available to you without prior authorization at the strength of 40mg/ml on the formulary.  A physician reviewed your appeal and determined that the plan is not required to cover Megestrol Acetate Suspension.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Procrit 4,000 units prescribed weekly for the treatment of anemia due to stage 4 chronic kidney disease in an enrollee not on dialysis. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription biologics. If prior approval is not obtained, the plan may not cover the biologic. 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. We also researched Medicare systems and reviewed the enrollment data available.We asked you to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication.The medical records show you prescribed Procrit to treat the enrollees anemia due to stage 4 chronic kidney disease. The Medicare approved compendia do support the use of this biologic for this condition. The plan requires a pretreatment hemoglobin greater than 10 grams per deciliter but no more than 13 grams per deciliter when Procrit is being used to reduce the need for allogeneic red blood cell transfusion in a patient schedule to undergo elective, non-cardiac, nonvascular surgery before they will cover the requested drug. You have verbally notified us that the enrollee is not using Procrit to reduce the need for allogeneic red blood cell transfusion in a patient schedule to undergo elective, non-cardiac, nonvascular surgery. The medical records submitted indicate that Procrit is being used to treat anemia secondary to stage 4 chronic kidney disease for an enrollee not on dialysis. The medical records also support a pretreatment hemoglobin level less than 10 grams per deciliter. The documentation provided does show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Briviact 100 milligram tablets to treat a seizure disorder. 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.Briviact 100 mg tablet is a brand drug on Tier 3 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 Prolia 60 milligrams prescribed 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.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

You requested Vraylar 1.5 milligrams prescribed for bipolar disorder, unspecified. The Part D plan denied your request because it does not meet the criteria of 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Vraylar 1.5 milligrams to treat your bipolar disorder, unspecified. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not support the use of this drug for your 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 Vraylar 1.5 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent patches prescribed daily for bilateral knee osteoarthritis. 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. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Lidocaine for bilateral knee osteoarthritis. In review of the Medicare approved compendia, bilateral knee osteoarthritis is not a medically accepted indication for Lidocaine. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Lidocaine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tresiba, 200 units per milliliter injection prescribed for diabetes. The Part D Plan denied your request for a lower-cost tiering exception because the medication is not included on the plans formulary. 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 physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.Tresiba is not included on your plans formulary. While the plan has approved the request for coverage of the non-formulary medication, a lower-cost tiering exception cannot be approved. The plan does not grant tiering exceptions to non-formulary drugs. Therefore, the Tresiba is not eligible for coverage at a lower-cost tier.