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

At issue is coverage for Budesonide EC 3 milligram capsules. Part D plan denied the request for coverage stating that the medication was being used for a non-medically accepted indication.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 indicates that the Budesonide EC is being prescribed for immunoglobulin A nephropathy prophylaxis. The submitted medical records support that the enrollee has immunoglobulin A neuropathy and end stage renal disease requiring a kidney transplant in October 2019. The Medicare approved compendium, DrugDex Information System, lists slowing the progression of immunoglobulin A nephropathy and delaying kidney failure in patients affected by the disease as an acceptable orphan drug designation for the use of Budesonide EC.However, the Part D plan has prior authorization requirements that must be satisfied prior to providing coverage for Budesonide EC. The submitted documentation does not support that the plans prior authorization requirements for this medication have been met. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Avycaz 2.5 microgram intravenous solution prescribed as directed for osteomyelitis of the right middle finger. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Avycaz to treat your osteomyelitis of the right middle finger. 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 the Avycaz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Venclexta Starter Pack prescribed as directed for chronic lymphocytic leukemia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee is receiving first line treatment for chronic lymphocytic leukemia with Venclexta, Umbralisib, and Ublituximab, as part of clinical trial sponsored by TG Therapeutics. This trial sponsor is not listed as one of the qualifying agencies/sponsors. The Part D plan only allows coverage for Part D eligible drugs used in federally funded trials. Furthermore, this drug is not eligible for Part D coverage because the Medicare approved compendia do not support the use of Venclexta, in combination with Umbralisib and Ublituximab, for the treatment of the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover the Venclexta Starter Pack.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Tobrex 0.3 percent ophthalmic ointment prescribed for bilateral exposure keratoconjunctivitis and prophylaxis of bacterial conjunctivitis. The Part D plan denied your request for a tiering exception because Tobrex is a brand name Tier 4 drug and the lower cost-sharing tiers do not contain any alternative drugs for 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. The plan shows Tobrex is a brand name Tier 4 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for a tiering exception for Entacapone 200 milligram tablets prescribed for the management of Parkinsons disease. 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.Entacapone is a generic drug on Tier 3 of the plans formulary. The prescriber has not addressed why the generic drugs of the same type on the lower tiers of the plans formulary to treat the noted condition have been tried and failed, or are contraindicated. A physician reviewed the appeal and determined that the plan is not required to grant a tiering exception to the Entacapone at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nadolol 20-milligram tablet to treat the enrollees condition. 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.At reconsideration a diagnosis was not given. No medical records were provided by the prescriber. It could not be determined if 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: Favorable

You requested Afinitor 10 milligram tablets prescribed as directed for recurrent meningioma. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the physician prescribed Afinitor to treat an enrollee with recurrent meningioma, including atypical meningioma (World Health Organization grade 2). The enrollee has been treated with multiple surgeries and radiation. Imaging performed in December 2020 showed disease progression; the enrollee is not a candidate for additional surgery or radiation.The National Comprehensive Cancer Network guidelines show that Afinitor, in combination with Avastin, can be used to treat unresectable progressive meningioma. This enrollee is not a candidate for treatment with Avastin due to comorbidities and age. An article from the Journal of Clinical Cancer Research regarding the use of Afinitor and Octreotide shows a 50% decrease of growth in 78% of patients with meningioma who are not candidates for surgery or radiation. As such, the Medicare approved compendia support the use of this drug for the enrollee and an exception to the plans prior authorization criteria is medically necessary. A physician reviewed your appeal and determined that the plan is required to cover Afinitor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Gammaked 10 gram per 100 milliliter vial. 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 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 Gammaked has been prescribed for the treatment of idiopathic autonomic neuropathy and small fiber neuropathy. 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 drug is being prescribed for non-medically accepted indications and 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 Gammaked.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Tresiba 100 units/milliliter pen injector 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.Tresiba 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

You requested Armour Thyroid 90 milligram tablets prescribed for hypothyroiditis/goiter. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows your physician prescribed Armour Thyroid for hypothyroiditis/goiter. The drug at issue is not Food and Drug Administration approved. Therefore, the drug cannot be considered a Part D benefit.We determined that the plan is not required to cover Armout Thyroid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Trulance 3 milligram tablets  prescribed as directed for chronic idiopathic constipation. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Trulance.A physician reviewed your appeal and determined that the plan is not required to cover Trulance.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Everolimus 0.5-milligram tablet prescribed for post lung transplant prophylactic immunosuppression. 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 submitted documentation indicates your doctor prescribed for prophylactic immunosuppression following a lung transplant. 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 Lubiprostone 24 microgram capsule prescribed for chronic idiopathic constipation. This drug is not on your plan's formulary. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Lubiprostone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cinacalcet Hydrochloride 90-milligram tablet prescribed for dialysis-related services. The Part D plan denied your 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 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 and Medicare records indicate you are not covered by Medicare Part B. However, the documentation does not support a diagnosis or a medically accepted indication. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cosopt PF 2%/0.5% eye drops prescribed daily for the enrollees condition. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Cosopt PF is a non-formulary drug. Non-formulary drugs 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

At issue is Ciprofloxacin-Dexamethasone otic suspension prescribed for otalgia.   The Part D plan denied the request as not a medically accepted indication.  The requested drug is not on the plans formulary. 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.An office note of April 6, 2021, is provided that includes the diagnosis of acute otitis externa, a medically accepted indication. However, this drug is not on the plans formulary, and 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. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doxycycline Hyclate 100 milligram tablets to treat rheumatoid arthritis. 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. 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 Anoro Ellipta 62.5-25 micrograms inhaler prescribed as needed for chronic obstructive pulmonary disease. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Anoro Ellipta.A physician reviewed your appeal and  determined that the plan is not required to cover the Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyproheptadine Hydrochloride 4 milligram tablets prescribed for malnutrition. The Part D plan denied your request because this type of drug is excluded from Part D coverage. 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. We determined that the plan is not required to cover Cyproheptadine Hydrochloride because drugs when used for anorexia, weight loss, or weight gain 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

At issue is Testosterone 25M/2.5 GM gel packets to treat male hypogonadism. 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 provided addressed the plans coverage criteria, and those criteria were not satisfied. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Heparin sodium 5000 unit/milliliter vial prescribed daily for treatment of end stage renal disease. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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 Heparin sodium must be billed by the renal dialysis facility. We determined that the plan is not required to cover the Heparin sodium. Please submit your request for this drug through your dialysis provider.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Regranex 0.01% gel to treat type 1 diabetes mellitus with foot ulcer and non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin  The Part D plan auto-forwarded the case.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. However, we did not receive the documentation.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 this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Breo Ellipta 100-25 microgram inhaler to treat pulmonary adenocarcinoma.  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 Ampyra 10 milligram prescribed for your multiple sclerosis. The Part D plan denied coverage because medical necessity was not established. 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. The documentation supports the drug was prescribed for multiple sclerosis. However, you do not satisfy the plan's prior authorization coverage criteria.  Relevant medical records were requested and no medical records were provided.  A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mesalamine delayed release 1.2 gram tablet. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The physician submitted a supporting statement. The prescriber statement indicates that Mesalamine is prescribed to treat noninfective gastroenteritis and colitis, unspecified. Additional diagnoses include diarrhea, altered bowel function, and history of colon polyps. However, the Medicare approved compendia do not support the use of this drug for the enrollees conditions. 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 Mesalamine.