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

At issue is request for Breztri Aerosphere 160-9-4.8 microgram actuator inhalation. At coverage determination and redetermination diagnosis provided was bronchiectasis and mild persistent asthma. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. At reconsideration the diagnosis provided is severe persistent asthma, uncomplicated. The Medicare approved compendia do not support the use of this drug for your condition. Micromedex, a Medicare approved compendia states Budesonide/glycopyrrolate/formoterol inhalation aerosol (active ingredients in Breztri) is not indicated for the relief of acute bronchospasm or for the treatment of asthma. As the drug was not 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 Inrebic 100 milligram capsule to treat myeloproliferative neoplasm. The Part D plan denied the 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. 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.As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Forteo 620 microgram/2.48 milliliter injector pen (2 pens (4.8 ml) to treat hypoparathyroidism. The Part D plan denied the request as use was for a non-medically acceptable indication. We received a 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 enrollee had been managed with Natpara injection (on formulary)  a parathyroid hormone treatment. The prescriber indicated this drug is not available, and is in shortage. This is confirmed on the FDA website, updated in December 2020.The request is for Forteo, teriparatide, 20 mcg injection twice daily. This drug has an orphan drug designation for treatment of hypoparathyroidism. The drug is on the plans formulary. Therefore it is considered a medically accepted indication.The drug is subject to utilization management criteria. The documentation does not satisfy the plans coverage criteria.  However, the prescriber has indicated why all alternatives required by the plan would likely not be as effective as the requested drug for you, or would likely cause adverse reaction(s). Therefore, an exception to the plans coverage criteria is medically necessary. The plan limits the amount of Forteo to 1 pen (2.4 ml)/28 days. The requested amount 2 pens (4.8 ml) is consistent with the dosage prescribed for treating this condition. The prescriber has indicated that the number of doses of the requested drug allowed by the plan would not been effective in treating the condition.  Therefore, an exception to the plans quantity limit coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage. The drug is only supplied as 600 mcg/2.4 ml. prefilled pen injector. Coverage for 2 pens/28 days (4.8 ml) as requested should be covered by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitriol 0.25 microgram capsules prescribed for end stage renal disease. The Part D plan denied the 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 record shows your doctor prescribed the medication to treat your end stage renal disease. Medicare pays certain drugs for dialysis patients under the bundled payment to your dialysis facility. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Calcitriol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 microgram inhaler to treat chronic obstructive pulmonary disease. The Part D plan denied the request.  The requested drug is not on the plans formulary. We received a 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria. The prescriber has not indicated the dates that the patient tried the alternatives. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% patch prescribed as directed for a strain of the muscle, fascia, and tendon of the lower back and pelvis and a laceration of the muscle, fascia, and tendon of the abdomen, lower back, and pelvis. The Part D plan denied the 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. No medical records were provided by the prescriber. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Diclofenac Epolamine because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron Hydrochloride 4 milligram tablet to treat nausea and vomiting. The Part D plan denied the 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 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. The plan limits the amount of Ondansetron Hydrochloride 4 milligram tablet to 12 per 4 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. Therefore, an exception to the plans quantity coverage criteria is not supported. The requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligrams/milliliter autoinjector prescribed every two weeks for an enrollee with established cardiovascular disease to reduce the risk of myocardial infarction, stoke, and coronary revascularization. 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 records submitted do not adequately show why the enrollee cannot take other medications on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick 140 milligrams/milliliter autoinjector.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prempro 0.3-1.5 milligram prescribed for hot flashes secondary to menopause. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee is using Prempro for menopause symptoms. We asked the prescriber to send us documentation supporting why you need this off-formulary medication. We received the documentation and included it in our review. The records submitted do not support why formulary alternatives would not be effective for the enrollee.A physician reviewed your appeal and determined that the plan is not required to cover the Prempro 0.3-1.5 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sucraid 8500 units per milliliter solution to treat congenital sucrase-Isomaltase deficiency. The Part D plan denied the 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.A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records. We received the documentation and included it in our review.The documentation provided addressed the plans coverage criteria and those criteria were not satisfied. 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 Omega 3 acid ethyl esters 1 gram capsules prescribed as directed to treat hyperlipidemia. The Part D plan denied the 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. No medical records were provided by the prescriber. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Omega 3 acid ethyl esters because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vimpat tablets to treat mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.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

You requested Trelegy Ellipta 100-62.5-25 micrograms/actuation inhaler prescribed as directed for chronic obstructive pulmonary disease. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The records do not show why the enrollee cannot use alternative drugs on the plans formulary to treat their condition.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 Dextraoamphetamine/Amphetamine 20 milligram tablets prescribed daily for fatigue related to multiple sclerosis. 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 also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Dextraoamphetamine/Amphetamine to treat your fatigue related to multiple sclerosis. However, 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 the Dextraoamphetamine/Amphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lubiprostone 24 microgram capsules prescribed for paralytic ileus. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Lubiprostone for paralytic ileus. The appeal request indicates the diagnosis should be irritable bowel syndrome with constipation; however, a change in diagnosis is not corroborated by the medical records submitted. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not 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 Flector 1.3% patch prescribed twice daily for sprain of ligaments of lumbar spine. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover the Flector patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus 0.5 milligrams capsules for kidney transplant status. 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. We also researched Medicare systems and reviewed the enrollment data available.The physician submitted a supporting statement. The prescriber statement indicates that Tacrolimus is prescribed for antirejection, and that the enrollee received their transplant before receiving Medicare benefits.However, medical records have not been submitted for review. Therefore, the documentation available does not show the enrollee has satisfied the plan's coverage criteria. Based on the information provided, the drug is not eligible for Part D coverage in this case.  A physician reviewed your appeal and determined that the plan is not required to cover Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vyvanse 30 milligram capsules prescribed daily for obsessive compulsive disorder. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Vyvanse for obsessive compulsive disorder. The Medicare approved compendia do not support the use of the drug for your condition. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armour Thyroid 90 milligram tablets prescribed daily for hypothyroidism. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We determined that the plan is not required to cover Armour Thyroid because it does not have an approved drug application with the Food and Drug Administration. Non-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. Based on this, the product is not considered a Part D eligible drug and as such is not eligible for coverage under a Part D prescription program. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Anoro Ellipta 62.5-25 microgram inhaler to treat the enrollees condition. The Part D plan denied the 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.Anoro Ellipta 62.5-25 microgram inhaler 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

You requested Tymlos 80 micrograms for subcutaneous injection prescribed as directed for steroid-induced osteoporosis with multi-level fragility fracture in a male. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the physician prescribed Tymlos for steroid-induced osteoporosis with multi-level fragility fracture in a male. 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 Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Phytonadione 5 milligram tablets prescribed to treat severe thrombocytopenia. 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. Vitamins and minerals are excluded from coverage under Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Phytonadione.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humulin R 100 units/milliliter prescribed 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. The record shows you prescribed Humulin R 100units/milliliter for diabetes treatment. We asked for information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review. The records do not show why the enrollee cannot take other biologics on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Humulin R 100 units/milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Biktarvy 50-200-25 milligram tablet prescribed as directed for human immunodeficiency virus. 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. Biktarvy 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 grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Eliquis 5 milligram tablets. 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. Eliquis is not included in the plans formulary. The plan does not grant tiering exceptions to non-formulary drugs. Therefore, the Eliquis is not eligible for coverage at a lower-cost tier. A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.