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

You requested Amitiza 24 microgram capsules prescribed two capsules daily for constipation, unspecified. The Part D plan denied your request at redetermination because the diagnosis is 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. You have submitted a statement indicating the diagnosis of opioid-induced constipation.  You have not submitted medical records to substantiate the new diagnosis.  The Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of constipation, unspecified.  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 Amitiza.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Esbriet 267 milligram tablet to treat idiopathic pulmonary fibrosis. 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 plan denied the appeal because the prescriber had stated that the enrollee had prior exposure to asbestos. In the reconsideration appeal dated February 18, 2021, the prescriber explained that this had been an error and that the enrollee had no known history of exposure. The prescriber also provided supporting medical records. The documentation satisfies the plans coverage criteria. 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 Azulfidine Entabs 500 milligrams to treat osteoarthritis cervical spine, primary osteoarthritis, and spondyloarthropathy. The Part D plan denied the request stating that the provided diagnosis is 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 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 requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise 600 milligrams prescribed for an unknown diagnosis.  The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an auto-forwarded 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 information submitted at the reconsideration level.The prescriber was asked to state the diagnosis since the diagnosis was not contained within the appeal.  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 exception criteria.  A response from the prescriber was not received.  Therefore, based upon the current record, 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Enbrel 50 milligrams/milliliter prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the biologic at issue is on a specialty tier and is not eligible for 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.Enbrel 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 coverage for Kineret 100 milligrams per 0.67-milliliter injection prescribed daily for hidradenitis suppurativa. The Part D plan denied the request stating that the prior authorization criteria are not met since the provided diagnosis is a non-medically accepted indication. 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 information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of your condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Toviaz 8 milligrams to treat the enrollees condition. 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 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.Toviaz is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Idhifa 100 milligram tablet to treat metastatic cholangiocarcinoma with isocitrate dehydrogenase-2 (IDH2) mutation. The Part D plan denied the request stating that the provided diagnosis is 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Humulin KwikPen 500 units/milliliter injection pen prescribed as directed for type II diabetes mellitus. The Part D plan denied your request for a tiering 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. Humulin KwikPen is a brand drug on Tier 5, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the specialty tier from the tiering exception process. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Humulin KwikPen. A tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gattex Kit to treat an enrollee with short bowel syndrome, dependent on parenteral support. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria. 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 Biktarvy 25 milligrams prescribed daily for HIV infection. The Part D plan denied your request for a tiering request because Biktarvy is in the specialty tier of your list of covered drugs. 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 Biktarvy is being prescribed for HIV infection. The Medicare approved compendia support the use of the requested drug for your condition. The plan shows Biktarvy is a brand name Tier 5 drug. Your plan does not allow you to receive drugs in this tier at a lower cost share.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Buprenex 0.3 milligrams per milliliter, 180 ampules per 30 days 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 drug is not on the plans formulary. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Avonex 30 micrograms/5 milliliter auto injector was prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for 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.Avonex is on the specialty tier of your plans formulary. Drugs 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: Favorable

At issue is Tacrolimus 1 milligram prescribed daily following a kidney transplant that was performed on June 17, 2014. The Part D plan denied your request to cover the medication under Part D. 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 other information submitted at the reconsideration level.The record shows that your doctor prescribed Tacrolimus as an immunosuppressive drug following your kidney transplant. Medicare records indicate you were not covered under Part A at the time of your transplant. Therefore, Tacrolimus is covered under Medicare Part D. As such, our decision is that the Part D plan is required to cover Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estrace 0.01 percent vaginal cream to treat atrophic vaginitis. 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

You requested coverage for Guanfacine 1 milligram tablet prescribed daily for anxiety disorder due to known physiological condition. 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 Guanfacine for anxiety disorder due to known physiological condition.In review of the Medicare approved compendia, anxiety disorder due to known physiological condition is not a medically accepted indication for Guanfacine. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Guanfacine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Linzess 72 microgram capsules to treat chronic constipation. 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 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.Linzess is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Estradiol 10 microgram tablets to treat postmenopausal atrophic vaginitis. 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 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.Estradiol is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xolair 150 milligram subcutaneous injections prescribed for bullous pemphigoid. The Part D plan denied your request because 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 Xolair for bullous pemphigoid. However, the Medicare approved compendia do not support the use of Xolair for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Xolair.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gleostine capsules prescribed for the treatment of glioblastoma multiforme. The Part D plan denied your request because the drug was excluded from coverage under Medicare Part D because it is a brand drug, and its manufacturer has not signed the Medicare Coverage Gap Discount Agreement. 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 Gleostine is excluded from coverage under Medicare Part D because it is a brand drug and its manufacturer has not signed the Medicare Coverage Gap Discount Agreement. 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, 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 Trulicity 0.75 milligrams per 0.5-milliliter pen injector to treat Type II diabetes mellitus in conjunction with diet and exercise. 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 documentation satisfies the plans coverage criteria. The prescriber provided medical records that substantiated the diagnosis. The office notes indicate that the enrollee will be changing his diet and increasing his exercise and will be using the requested drug to improve blood sugar control.   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 Abiraterone acetate 250 milligram tablets to treat malignant neoplasm of the prostate. The Part D plan denied the request 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 information submitted at the reconsideration level.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Acetaminophen ER 650 milligrams prescribed three time daily for fibromyalgia. The Part D plan denied your request because over-the-counter drug products are excluded from coverage under Medicare Part D. 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 also researched Medicare systems and reviewed the enrollment data available.We determined that the plan is not required to cover Acetaminophen ER 650 milligrams because it is an over-the-counter drug product. Nonprescription, or over-the-counter drugs, are excluded from 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

You requested the Diphtheria, Tetanus, and Acellular Pertussis Booster Vaccine (TDAP) injection. 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 an auto-forwarded reconsideration request from the enrollee.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 show you have a receipt for the TDAP vaccine and are requesting reimbursement. A physician reviewed your appeal and determined that the TDAP is usually categorized as preventive and therefore not covered unless there is a specific covered diagnosis. Therefore, the drug cannot be considered for payment under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine hydrochloride 2 milligram sublingual tablets prescribed as directed for pain related to metastatic breast cancer. The Part D plan denied your request because 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 documentation shows the doctor prescribed Buprenorphine hydrochloride sublingual tablets for pain related to metastatic breast cancer. However, the Medicare approved compendia do not support the use of this drug in sublingual form for pain related to metastatic breast cancer.A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Favorable

You requested Shingrix Vial Kit prescribed two injections for shingles vaccination. The Part D plan denied the request because there was no proof of payment from your doctors office. We received a request to reconsider the appeal. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.Your record shows you received the vaccinations at Marshfield Clinic. The records show Marshfield Clinic administered and billed you for the Shingrix vaccinations with service dates of June 18, 2020, and September 28, 2020. You have submitted proof of payment from Marshfield Clinic, which satisfies the plans reimbursement criterion.We determined that the plan is required to provide reimbursement for the two Shingrix vaccinations and administration fees.