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

At issue is Freestyle Libre 10 Day Sensor. 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. 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. We also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the Freestyle Libre 10 Day Sensor may be eligible for coverage under Part B under Medicare rules.  A physician reviewed the appeal and determined that the requested Freestyle Libre 10 Day Sensor is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Colistimethate Sodium 150 milligram solution prescribed for chronic colonized pseudomonas due to the presence of late-onset Tay-Sachs disease with resultant progressive neuromuscular difficulties. 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 does not satisfy the plans coverage criteria. The prescriber has addressed the prior authorization criteria; however, the responses do not satisfy all of the plans requirements for coverage of this medication. 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 Armour Thyroid 120 milligrams to treat hypothyroidism. 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.Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Per the Medicare approved compendia, This drug has not been found by the United States Food and Drug Administration to be safe and effective, and the drug product labeling has not been approved by the Food and Drug Administration. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mycophenolate Mofetil 250 milligram capsule twice daily for lung transplant rejection prophylaxis. 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. 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 D. There is no information in the Medicare Database that indicates you had a covered transplant paid for by Medicare. This drug in on the plans formulary and being used for a medically accepted indication.The following citation in American Hospital Formulary Service-Drug Information (AHFS-DI), a Medicare approved compendium, supports the use of the requested drug for your condition:  Mycophenolate Mofetil and Mycophenolate Sodium have been used for the prevention of rejection of lung allografts in patients who have undergone lung transplantation. Therefore, it is considered a medically accepted indication.A physician reviewed the appeal and determined that the requested drug should be covered by the Part D plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lubiprostone 8 microgram capsules prescribed to treat constipation. The Part D plan denied your request for a formulary exception. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. The records do not show why the enrollee cannot take all other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Lubiprostone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sandimmune ampule 250mg/5ml  5 ampules/14 days. The Part D plan denied your request as not a medically accepted indication as ordered.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 physician submitted a supporting statement. The prescriber statement indicates that Sandimmune ampule 250mg/5ml is prescribed for dry eye syndrome. Medical records have not been submitted for review. The Medicare approved compendia do not support the use of the requested drug, as ordered, for the diagnosis provided. It is not a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Sandimmune.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Betoptic S 0.25% eye-drops prescribed for primary open-angle glaucoma. 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 records submitted at the reconsideration level. Your physician submitted a supporting statement. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Betoptic S.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Corlanor 5 milligram tablets prescribed for postural orthostatic tachycardia syndrome. 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 Corlanor for postural orthostatic tachycardia syndrome.In review of the Medicare approved compendia, postural orthostatic tachycardia syndrome is not a medically accepted indication for Corlanor. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Corlanor at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine Ointment 5% prescribed to treat chronic pain disorder, neuropathic pain, cervical cord myelomalacia, paraparesis of both lower limbs, impairment of balance, and polyneuropathy. 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. 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 Lidocaine ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Repatha Sureclick 140 milligrams. 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. Repatha Sureclick is a biological drug on Tier 3 of the plans formulary. It is covered at the cost-sharing tier listed in your 2021 drug guide and there are no lower cost biological drugs, of the same type, in 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 Takhzyro treat hereditary angioedema. The Part D plan denied a request for this drug. We received an expedited reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation does not satisfy an exception to the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trileptal 360 tablets for a 90 day supply to treat seizures. The Part D plan denied your 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. Trileptal is a specialty drug, which is limited to a 30 day supply. The documentation indicates that this drug is approved as a recurring 30 day supply. As such, specialty drugs are not available for a 90 day supply.In conclusion, our decision is unfavorable.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin-Dipyridamole 25-200 milligram capsules prescribed daily for the enrollees condition. 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.Aspirin-Dipyridamole is a generic drug on Tier 4 of the plans formulary. Your doctor submitted a supporting statement. The statement did not address why all alternative lower-tier medication on the plans formulary would not work for you. All generic drugs on lower tiers have not been tried. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Victoza 0.6 milligram/0.1 milliliter subcutaneous solution prescribed for the enrollees condition. 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.Victoza is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine Patch 5% prescribed every 12 hours to treat primary osteoarthritis of the right ankle and foot. 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. 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 Lidocaine Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligram ER tablets prescribed for the enrollees condition. 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.Myrbetriq is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Siliq Solution Prefilled Syringe. The Part D plan denied a request for this drug. 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 physician submitted a supporting statement. The prescriber statement indicates that Siliq Solution Prefilled Syringe is prescribed to treat hidradenitis suppurativa. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s).A physician reviewed your appeal and determined that the plan is not required to cover Siliq Solution Prefilled Syringe.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Qdolo 5 milligram/milliliter solution prescribed as directed for chronic 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. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the February 2021 published list, the manufacturer, Athena Bioscience, LLC, signed the agreement and does participate in the Medicare Gap Discount Program. Therefore, this drug may be eligible for coverage under Part D. The plan has excluded this drug from its formulary. As such, the drug requires further review to determine if it should be covered by the plan. The record shows the physician prescribed Qdolo for an enrollee with chronic pain. The physician states the enrollee requires medication in liquid form for administration via gastrostomy tube. However, the records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. Many of the formulary alternatives are available in liquid form.A physician reviewed your appeal and determined that the plan is not required to cover Qdolo.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Verzenio 150 milligram tablet prescribed for ER positive HER2 negative right breast 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 medical records show you prescribed Verzenio in combination with endocrine therapy. The prescriber submitted a Phase 3 trial titled Primary Outcome Analysis of Invasive Disease-Free Survival for MonarchE: Abemaciclib Combined with Adjuvant Endocrine Therapy for High-Risk Early Breast Cancer published by Journal of Clinical Oncology. The enrollee meets the study criteria as she has high-risk disease with high proliferation rate and a tumor 5.0 centimeters in size. The Medicare approved journal supports the use of Verzenio for the enrollees condition. Therefore, payment can be allowed.  An oncologist reviewed your appeal and determined that the plan is required to cover Verzenio 150 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligram/2 milliliter syringe prescribed for atopic dermatitis. 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.Dupixent is on the specialty tier of your plans formulary. Biologics that are on the plans specialty tier are 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 Methadone Hydrochloride 10 milligram tablets prescribed to treat chronic pain 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. The physician did not submit documentation to support that the benefits of the drug outweighs the potential risks. The prescriber needs to verify that both Methadone and drugs already being taken, Clonazepam and Hydromorphine, are all medically necessary or if one or more will be discontinued. A physician reviewed your appeal and determined that the plan is not required to cover Methadone Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Anoro Ellipta 62.5-025 microgram inhalation powder prescribed 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. Anoro Ellipta is not included in the Part D plans formulary. The prescriber has not sufficiently addressed why all alternative drugs included in the plan's formulary to treat this condition have been tried and failed or would likely not be as effective as the requested drug or would likely cause adverse reactions or other harm. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dextroamphetamine-Amphetamine 20 milligram tablets prescribed daily for major depressive 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 Dextroamphetamine-Amphetamine for major depressive disorder. 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 Calcipotriene Cream to treat plaque psoriasis. The Part D plan denied your request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. A physician reviewed your appeal and determined that the plan is not required to cover Calcipotriene Cream.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent patch prescribed as directed for left arm 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 also researched Medicare systems and reviewed the enrollment data available. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the prior authorization criteria for coverage are not met.A physician reviewed your appeal and  determined that the plan is not required to cover the Lidocaine 5 percent patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis five-milligram tablet prescribed twice daily for paroxysmal atrial fibrillation and persistent atrial fibrillation. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration 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 a brand drug on Tier 3 of the plans formulary. Your doctor did not address why the medications would not work for you. All brand drugs on lower tiers have not been tried. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Methylphenidate Hydrochloride 20 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. The record indicates that Methylphenidate Hydrochloride has been prescribed for the treatment of multiple sclerosis related fatigue. 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 prescriber has not sufficiently addressed the plans prior authorization criteria and/or the coverage criteria are not satisfied by the provided medical records.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tymlos 80 micrograms for subcutaneous injection prescribed as directed for osteoporosis. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.We asked the prescriber to send us a supporting statement and medical records showing the medical necessity of Tymlos. We received the documentation and included it in our review.The record shows the physician prescribed Tymlos for a postmenopausal enrollee with osteoporosis and a history of a low trauma fracture to the left tibia. However, the record does not show the enrollee has satisfied the plans coverage criteria. A physician reviewed your appeal and determined that the plan is not required to cover the Tymlos.