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

At issue is Tacrolimus 4 milligram capsules prescribed following a kidney transplant. The Part D plan denied your request to cover the medication under Part D. 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 other information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The record shows that Tacrolimus has been prescribed as an immunosuppressive drug following a kidney transplant that took place on January 17, 2006. Medicare records show the patient was enrolled in Medicare Part A from January 1, 2006, though January 31, 2009, and then enrolled again in August 1, 2011. Therefore, Medicare records support that the patient was enrolled in Medicare Part A when the kidney transplant was performed. Since the patient was enrolled in Medicare Part A during the transplant, the Tacrolimus would be covered under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law. As such, our decision is that the Part D plan is not required to cover the Tacrolimus. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclophosphamide 50 milligram capsules prescribed as directed for other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records show the doctor prescribed Cyclophosphamide for other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors. The documentation shows this enrollee has fibromyalgia and discoid lupus. The enrollee also has lupus anti-coagulant and a prolonged activated partial thromboplastin time. 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 Cyclophosphamide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Repatha 140 milligrams for subcutaneous injection every two weeks. The Part D Plan denied your request because there were no other similar drugs on a lower cost-sharing tier. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Repatha is a biologic drug on Tier 4 of the plans formulary. There are no biologic drugs of the same type on the lower cost sharing tiers. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. Therefore, a tiering exception cannot be granted.A physician reviewed your appeal and determined that the plan is not required to cover the Repatha at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Loteprednol Etabonate 0.5% ophthalmic suspension. The Part D plan denied the request stating that the medication was prescribed for a non-medically accepted 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 documentation indicates that Loteprednol Etabonate is being prescribed for monocular glaucoma and corneal transplant. 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 conditions. 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 Loteprednol Etabonate ophthalmic suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested compounded Intron A/Sodium Chloride eyedrops prescribed for ocular surface squamous neoplasia. 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 the compounded drug for ocular surface squamous neoplasia. This is an off-label use of the drug. The Medicare approved compendia do not contain citations to 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 Zetia 10 milligram tablet to treat the enrollees condition. 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 medical records show the requested drug is being prescribed to treat the enrollees condition. However, Zetia is not on the plans formulary. 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.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 Humulin N 100 units/milliliter insulin prescribed as directed for type II diabetes mellitus. The Part D plan denied your request for a tiering exception because there were no biologic drugs of the same type on the lower cost sharing tiers. 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. Humulin N 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. 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 Amitiza 24 microgram capsule prescribed for constipation. The plan denied the appeal because this drug is not listed on your formulary plan and you may not have tried the preferred drugs on your plans formulary. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Amitiza for your constipation. This drug is not listed in your plans formulary for your condition. Your doctor did not indicate that you tried the preferred drugs listed on your plans formulary for your condition and why they would not work just as well. Therefore, the requested drug cannot receive a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Amitiza because the documentation does not show that you have met the coverage criteria for a formulary exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrocodone Bitartrate and Acetaminophen 5 milligram-300 milligram compound powder for capsules. The Part D plan denied your request because one or more of the ingredients within the requested compounded medication belongs to a class of drugs that your plan does not include in their Part D coverage when part of a compound. 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. Medicare Part D provides coverage for compounded medications when the individual ingredients can be covered. Bulk powders (i.e., active pharmaceutical ingredients for compounding) do not satisfy the definition of a Part D drug and are not covered by Part D. Additionally, Acetaminophen as an individual medication is excluded from Medicare Part D coverage because it is an over the counter medication/nonprescription. Therefore, the Hydrocodone Bitartrate and Acetaminophen compound cannot be covered. 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 reimbursement for Morphine Sulfate Solution 100/5 milliliters. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The enrollee was in hospice care at the time the drug was received. This drug may be covered under the Medicare Part A Drug Benefit. Drugs used for hospice care must be sent to Medicare Part A. Drugs for health issues not related to end-of-life can be covered under Medicare Part D. However, there is no documents submitted that indicate the drug was for a condition unrelated to the enrollees hospice care. A physician reviewed your appeal and determined that the plan is not required to reimburse the cost of Morphine Sulfate Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyanocobalamin 1000 microgram injection prescribed for pernicious anemia. The Part D plan denied your request because prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations, are excluded from Part D coverage. 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 determined that the plan is not required to cover Cyanocobalamin because prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations, are excluded from Part D coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ofev 150 milligram oral capsule prescribed twice daily for chronic fibrosing interstitial lung disease with a progressing phenotype. The Part D plan denied your request for a tiering 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.Ofev is a brand drug on Tier 5 of the plans formulary. This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 150 milligram tablet prescribed for obstructive sleep apnea and narcolepsy. The plan denied the appeal because a lower cost-sharing amount for drugs that are not covered on the plans formulary, including non-formulary drugs that you may have asked to be covered as an exception, cannot be allowed. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Armodafinil for your obstructive sleep apnea and narcolepsy. This drug is not listed in your plans formulary for your condition. The documentation submitted does not indicate why the drugs listed on your plans formulary for your condition cannot work just as well. Therefore, the requested drug cannot receive a formulary exception or a cost-sharing tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover Armodafinil because the coverage criteria have not been met per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testopel 75 milligrams (8 pellets) injected every three months for hypogonadism. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received 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 record shows your doctor injects the medication in his office. This drug is eligible for coverage under Medicare Part B. Medicare Part D does not cover a drug that is being billed, dispensed, and administered by the physician in his office or infusion clinic.We determined that the plan is not required to cover Testopel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symbicort 160-4.5 micrograms prescribed two puffs twice a day for moderate persistent asthma . The Part D Plan denied your request for a tiering exception because there is not an alternative brand name drug for your condition in a lower cost-sharing tier. 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. Symbicort 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 Tadalafil 5 milligram tablet to treat benign prostatic hyperplasia.   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 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 Tysabri 300 milligrams/15 milliliter vial for intravenous infusion prescribed for multiple sclerosis. 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 physician states the enrollee has failed treatment with one other medication. 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 Tysabri.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dextraoamphetamine/Amphetamine 30 milligram capsules to treat chronic fatigue related to multiple sclerosis. The Part D plan denied your request because the provided diagnosis did not meet the criteria of a medically accepted indication. We received a reconsideration request.  We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Dextraoamphetamine/Amphetamine 30 milligram capsules twice daily to treat your chronic 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 Dextraoamphetamine/Amphetamine because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine patch 5 percent prescribed for hemiplegia following cerebral infarct, pain in the right toes and monoplegia lower limb. The Part D plan denied the request stating that the provided diagnosis is not a medically accepted 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 medical records indicate you were prescribed the Lidocaine patch 5 percent for hemiplegia following cerebral infarct, pain in the right toes and monoplegia lower limb. 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 requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligram tablets prescribed for statin associated necrotizing autoimmune myopathy. The Part D plan denied your request because the drug might be covered by Medicare Part B. The Part D plan also denied your request because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records show the doctor prescribed Mycophenolate Mofetil to treat statin associated necrotizing autoimmune myopathy. The documentation does not show that the medication was prescribed following a Medicare-covered organ transplant. Therefore, the drug would not be covered under Medicare Part B, and is eligible for consideration of Medicare Part D coverage. However, the Medicare approved compendia do not support the use of Mycophenolate Mofetil for the enrollees condition. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Mycophenolate Mofetil at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Alosetron HCL 1 milligram tablets prescribed twice daily for chronic diarrhea. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Alosetron HCL 1 milligram tablets to treat your chronic diarrhea. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and determined that the plan is not required to cover Alosetron HCL because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cresemba 186 milligram capsules prescribed for the prevention of fungal infections in an enrollee with acute myeloid leukemia and post bone marrow transplant for antifungal prophylaxis. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records show the enrollee has acute myeloid leukemia and is post bone marrow transplant. The doctor prescribed Cresemba to prevent fungal infections. The Medicare approved compendia do not support the use of this drug for the enrollees condition. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Cresemba at issue.