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

You requested Vyvanse 30 milligram capsules prescribed as directed for narcolepsy without cataplexy. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Vyvanse to treat your narcolepsy without cataplexy. 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 Vyvanse.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Gleostine 40 milligram capsule prescribed to treat glioblastoma. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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 list, the manufacturer, Nextsource Biotechnology, LLC, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Gleostine. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Auryxia 210-milligram tablet to treat other disorders of mineral metabolism and abnormal phosphorous. 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.At reconsideration, additional records were provided confirming the enrollee is receiving dialysis, and has the diagnosis of hyperphosphatemia due to secondary hyperparathyroidism. The Medicare approved compendia supports the use of this drug for your condition. Therefore, the requested drug is eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 10-millgram tablet. At initial determination and redetermination the diagnosis of muscle spasms secondary to chronic low back pain was given. 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.At reconsideration a diagnosis of muscle spasms due to acute musculoskeletal condition was given. No medical records were provided by the prescriber to support this diagnosis. 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nystatin 100,000-units/gram Powder to treat candidiasis of skin and nails. The Part D plan denied the request. The requested drug is not on the plans formulary. 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.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Prolastin-C Solution 1000 milligram/20 milliliter prescribed Alpha-1 Antitrypsin deficiency. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The documentation shows Prolastin-C was prescribed to treat Alpha-1 Antitrypsin deficiency. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. 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 Prolastin-C. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Shingrix 50/0.5 milliliter vial kit prescribed for vaccination. The Part D plan denied the enrollees 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 was administered the Shingrix vaccine at their physicians office. Payment for vaccines including administration fee is required up front when provided at an out-of-network pharmacy or provider's office. The enrollee will be reimbursed the amount paid less any deductible, copayment or coinsurance and less the amount the physician charges and the plans approved amount. The enrollee submitted documentation including a physicians invoice. However, there is no receipt showing the enrollee paid the full amount of the vaccine and administration fee, as required by the plans Evidence of Coverage. Therefore, we determined that the plan is not required to reimburse the enrollee for the vaccine and administration fee at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 30 milligram tablets to treat hypothyroidism. The Part D plan denied the request because the drug is not listed on the plans formulary.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.Non-FDA approved drugs are excluded from Medicare Part D coverage.  Therefore, Armour Thyroid is excluded from coverage. Since Armour Thyroid is excluded from coverage the plans formulary exception requirements are not applicable to this review.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100-62.5 microgram blisters with device. 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. Trelegy Ellipta 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 Lotemax 0.5% ophthalmic gel prescribed for dry eyes. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Lotemax to treat your dry eyes. 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 Lotemax.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Suprep Bowel Prep Kit. 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. We asked your prescriber to send us additional documentation to show us why the drugs on the lower tiers of the plans formulary would not work. A reply from the prescriber was not received. Suprep Bowel Prep Kit is a brand drug on Tier 4 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  Therefore, this drug is not eligible for a tiering exception.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

The enrollee requested Tacrolimus 1 milligram prescribed daily for the prevention of kidney transplant rejection. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is not required to cover the Tacrolimus. Medicare records indicate the enrollee received a kidney transplant on July 14, 2014, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Tacrolimus is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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: Favorable

At issue is Modafinil 200 milligram tablet prescribed for fatigue related to multiple sclerosis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records shows Modafinil was prescribed to treat the enrollees fatigue related to multiple sclerosis. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for the enrollees condition: Interestingly, in a 9-week, phase 2, single-blind, 2-center, pilot study (n=72), 2 weeks of Modafinil 200 milligram daily significantly improved fatigue severity scale scores compared with placebo in patients with multiple sclerosis.A physician reviewed your appeal and determined that the plan is required cover Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azelastine 0.1% Spray. At initial determination and redetermination the diagnosis of acute nasopharyngitis (common cold) (J00) was given. 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.At reconsideration a diagnosis of seasonal allergic rhinitis (J30.1) was given. No medical records were provided by the prescriber to support this change in diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Additionally, Azelastine is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception or 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: Favorable

At issue is Testosterone 1.62% gel prescribed for testicular hypofunction. 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 records submitted at the reconsideration level. The plan has prior authorization criteria that must be met for continuation of Testosterone 1.62% gel use. A total testosterone level from within the past 12 months has been submitted, and is below the lower limit of normal for the lab. Therefore, the prior authorization criteria has been met for continuation of the requested drug. A physician reviewed your appeal and determined that the plan is required to cover Testosterone 1.62% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested multi-drug Hydrochloric Acid, Sodium Hydroxide pellets, Bromfenac bulk powder, Prednisolone Sodium bulk powder, Boric Acid bulk powder, Gatifloxacin Sesquinhydrate powder, and sterile water compound prescribed for unknown diagnosis. The plan denied the enrollees 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, drugs that fall into the category of bulk powders are excluded from coverage under Part D. The Bromfenac bulk powder, Prednisolone Sodium bulk powder, Boric Acid bulk powder, and Gatifloxacin Sesquinhydrate powder do not meet the definition of  Part D drugs. In addition, Medicare Part D does not cover non-prescription drugs. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drugs are non-prescription or over-the-counter (OTC) drugs. Therefore, the ingredients Hydrochloric Acid, Sodium Hydroxide, and Sterile Water are not eligible for Part D coverage. Therefore, we determined that the plan is not required to cover the Hydrochloric Acid, Sodium Hydroxide pellets, Bromfenac bulk powder, Prednisolone Sodium bulk powder, Boric Acid bulk powder, Gatifloxacin Sesquinhydrate powder, and sterile water compound. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Simponi Aria 50 milligram/4-milliliter intravenous solution prescribed as directed for rheumatoid arthritis without rheumatoid factor, multiple sites. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to 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 formulary coverage criteria is not supported. A physician reviewed your appeal and determined that the plan is not required to cover Simponi Aria.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Adderall XR 20 milligram extended release tablets prescribed for attention deficit hyperactivity disorder. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Adderall XR is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient clinical rationale as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine Hydrochloride 6.25 milligram per 5 milliliters oral syrup prescribed to treat an enrollee with chemotherapy-induced nausea and vomiting. The Part D plan denied the appeal request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Promethazine Hydrochloride 6.25 milligram per 5 milliliters oral syrup to treat chemotherapy-induced nausea and vomiting. 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 drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the plan is not required to cover Promethazine Hydrochloride 6.25 milligram per 5 milliliters oral syrup.
Appeal type: Prescription Drug
Decision: Favorable

You requested Retacrit 20,000 units prescribed for anemia due to myelodysplastic syndrome. The Part D plan denied your request because prior authorization requirements were not met. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. 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 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 documentation shows Retacrit was prescribed treat anemia due to myelodysplastic syndrome. Retacrit has a Food and Drug Administration orphan drug designation for treatment of myelodysplastic syndrome.  The prescriber provided laboratory results from date of service 8/13/2021, which documented a hemoglobin level of 6.3 g/dL.   The documentation includes clinical notes which satisfied the plan's coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.A physician reviewed your appeal and determined that the plan is required to cover Retacrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 620-micrograms/2.48-milliliters to treat age-related osteoporosis with current pathological fracture, unspecified site, initial encounter for fracture. 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.Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.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 Emgality 120 milligram/milliliter solution auto injector  prescribed as directed for migraine, unspecified, not intractable, without status migrainosus. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Emgality.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is NP Thyroid 30 milligram tablet prescribed for hypothyroidism. 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.Non-FDA approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to cover NP Thyroid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Inbrija 42-milligram Inhalation Capsule to treat Parkinsons disease. The Part D plan denied the request. The requested drug is not on the plans formulary. 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.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, no medical records were provided to support why other drugs on the plans formulary would not work for you.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.