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

At issue is Dulera Aerosol 100 microgram-5 microgram/actuation inhaler to treat chronic obstructive pulmonary disease. The Part D plan denied the request for an off-formulary exception.  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 prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the plans formulary alternatives. We did not receive the documentation requested.The prescriber has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans 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 Uceris 2 milligram aerosol foam prescribed for ulcerative colitis. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 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 Uceris.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Methylphenidate 10 milligram tablets prescribed for hypersomnia. 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 Methylphenidate for hypersomnia.In review of the Medicare approved compendia, hypersomnia is not a medically accepted indication for Methylphenidate. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Methylphenidate at issue.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Cyclosporine modified 25 milligram capsules prescribed for kidney transplant. The Part D plan denied the request because the enrollee was eligible for Medicare Part B coverage at the time of transplant. We received a 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 determined that the plan is required to cover the Cyclosporine. The record shows the enrollee received a kidney transplant on January 12, 2015. Medicare records indicate the enrollee was not eligible for Part B until April 01, 2016. Therefore, the transplant was not eligible for coverage under Part B. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mavyret 100-40 milligram tablet prescribed as directed chronic viral hepatitis C. The Part D plan denied coverage because the plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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 medical records show your doctor prescribed Mavyret to treat your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover the Mavyret.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Pregabalin 25 milligrams prescribed for schizoaffective disorder. 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 Pregabalin for schizoaffective disorder. The Medicare approved compendia do not support the use of this drug for your condition. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Pregabalin at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligrams/ 2 milliliters subcutaneous injection prescribed as directed. The Part D plan denied coverage because the prior authorization criteria were not met. 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. The documentation shows the doctor prescriber Dupxient to treat an enrollee with moderate to severe oral corticosteroid dependent asthma. However, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Retacrit 10,000 unit/milliliter vial prescribed as directed following a kidney transplant and anemia. The Part D plan denied your request for a tiering exception because there were no brand drugs of the same type on the lower cost sharing tiers. 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.Retacrit 10,000 unit/milliliter vial 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.Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Praluent 150 milligram injectable pen prescribed for hyperlipidemia. 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 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 drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gabapentin 100 milligrams prescribed two capsules twice daily for alcohol induced disorder. The Part D plan denied your request because medical necessity was not established. 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.Gabapentin was ordered to treat the enrollees condition. However, the Medicare approved compendia do not support the use of this drug for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Gabapentin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Paxil 40 milligrams prescribed for anxiety disorder and major depression. 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 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 drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Freestyle Libre 14 Day Reader Device. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The Freestyle Libre 14 Day Reader Device would be eligible for coverage under Medicare Part B rules. Therefore, the Medicare Part D Prescription Drug benefit is not required to cover the medical equipment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cinacalcet hydrochloride prescribed for use with dialysis for end stage renal disease. The Part D plan denied your request because the drug is not eligible for coverage Part B or Part D. 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. According to Medicare rules, the requested drug cannot be approved for separate payment under Part B or Part D when their use is related to end stage renal disease and dialysis. The record shows the enrollee has end stage renal disease and is on dialysis. Therefore, the Cinacalcet hydrochloride must be billed by the renal dialysis facility. We determined that the plan is not required to cover the Cinacalet hydrochloride. Please submit your request for this drug through your dialysis provider.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide EC 3 milligram capsules prescribed for short bowel syndrome. The Part D plan denied your request because the 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. The submitted documentation indicates your doctor prescribed Budesonide EC for short bowel syndrome. 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 Trulicity 0.75 milligram/0.5 milliliter injection to treat uncontrolled type II diabetes mellitus. The Part D plan denied your request for a tiering exception. 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. Trulicity is a biologic drug on Tier 3 of the plans formulary. There are no biologic drugs of the same type on the lower cost sharing tiers. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Kineret 100 milligrams per 0.67-milliliter syringe prescribed for auto inflammatory 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 Kineret for auto inflammatory syndrome. The Medicare approved compendia do not support the use of this drug for your condition. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Kineret at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta ER 200 milligram tablets prescribed for cervical disc disorder. 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. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. 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 Nucynta ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Clobazam 10 milligram tablets prescribed for epilepsy with nocturnal seizures. 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 Clobazam for epilepsy with nocturnal seizures. In review of the Medicare approved compendia, epilepsy with nocturnal seizures is not a medically accepted indication for Clobazam. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Clobazam at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Dicyclomine Hydrochloride 10 milligram tablets prescribed for irritable bowel disease with constipation. The Part D plan denied your request for a tiering exception because Dicyclomine Hydrochloride is a generic Tier 3 drug and the lower cost-sharing tiers do not contain any alternative drugs to treat your condition. 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. The record shows Dicyclomine Hydrochloride is being prescribed for irritable bowel disease with constipation. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Dicyclomine Hydrochloride is a generic Tier 3 drug. The lower cost-sharing tiers do not contain any alternative drugs to treat your condition. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Promacta 50 milligram tablets prescribed as directed for severe thrombocytopenia and myelofibrosis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The prescriber statement shows the doctor prescribed Promacta for severe thrombocytopenia and myelofibrosis. However, the Medicare approved compendia do not support the use of this drug for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to cover Promacta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nulojix 250 milligrams for intravenous solution prescribed following a kidney transplant. The Part D plan denied your request for a formulary exception because there was insufficient documentation to show the drug was 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. The medical records show the prescribed Nulojix, in combination with Mycophenolate mofetil and Prednisone, to prevent rejection following a kidney transplant. The enrollee was noted to be Esptein-Barr virus seropositive in March 2019. The Medicare approved compendia support the use of this drug for the enrollees condition. The medical records show the enrollee failed treatment with Prograf. However, 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 Nulojix.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch to treat right shoulder pain. 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 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 diagnoses 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 your conditions. 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 Evenity 210 milligrams/2.34 milliliter subcutaneous injection prescribed for an enrollee with post-menopausal osteoporosis. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 asked the prescriber to send us a supporting statement and medical records to show why Evenity is medically necessary. We received the documentation and included it in our review.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 Evenity.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 20 milligram-10 milligram capsules prescribed for pseudobulbar affect. The Part D plan denied your request because the 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. The submitted documentation indicates your doctor prescribed Nuedexta for pseudobulbar affect not related to amyotrophic lateral sclerosis or multiple sclerosis. 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

You requested Olanzapine 2.5 milligram tablets prescribed as directed. The Part D plan denied your request for reimbursement because there was insufficient documentation. 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 asked the prescriber to send us information regarding the enrollees condition. We did not receive the documentation requested.The prescriber statement does not include the enrollees diagnosis for which Olanzapine was prescribed. In addition, 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 reimburse you for Olanzapine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol 0.083% nebulizer solution prescribed for asthma. The Part D plan denied the request. 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.The record shows your doctor prescribed the medication for asthma. The drug at issue is a medication used with a nebulizer. Part D does not cover drugs used with a nebulizer in your home. The documentation does not include medical records to support you are using this drug via nebulizer in a facility setting. The drug is eligible for coverage under Medicare Part B. Therefore, this is not considered a Part D drug.We determined that the plan is not required to cover Albuterol 0.083% nebulizer solution.