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

At issue is Alosetron 1-milligram tablet to treat chronic diarrhea. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.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 Buprenorphine Hydrochloride 2-milligram tablet sublingual to treat pain. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.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 Retacrit 10,000 units/ milliliters solution prescribed every two weeks for anemia in an enrollee with Stage 5 chronic kidney disease who is not on dialysis. The Part D plan denied the 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.We determined that the drug is not eligible for Part B coverage. Medicare records support you have not received dialysis since March 2, 2020. The claim cannot be considered part of a bundled prospective payment under an End-Stage Renal Disease facility administering dialysis. Therefore, the drug can be considered for payment under the Part D benefit. Your medical records show your doctor prescribed Retacrit to treat your anemia secondary to Stage 5 chronic kidney disease. Your hemoglobin levels are less than 10.0 grams/deciliter. The records provided with the Reconsideration request also support you are not receiving dialysis. The Medicare approved compendia supports the use of this drug for your condition.A physician reviewed your appeal and determined that the plan is required to cover Retacrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz 10-milligram tablet to treat alopecia areata. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.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 Humulin Kwikpen Solution Pen-Inject. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. We asked the prescriber to send us the case file. However, we did not receive the documentation. 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 a tiering exception request for Toujeo Solostar 300-units/milliliter to treat the enrollees diabetes mellitus. 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.Toujeo Solostar is a brand 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulicity Auto-Inject 1.5-milligrams/0.5-milliliter Pen-Inject. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. We asked the prescriber to send us the case file. However, we did not receive the documentation. 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 Carvedilol ER 10 milligram capsules to treat hypertension.  This diagnosis was submitted in the Reconsideration request.  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 diagnosis of hypertension was submitted in the Reconsideration request.  A request was submitted to the prescriber to provide supporting medical records. A reply from the prescriber was not received. 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.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 Januvia 50-milligram tablet to treat the enrollees Type 2 diabetes mellitus. 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.Januvia 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 Nuedexta 20 milligram-10 milligram capsules prescribed daily for personal history of traumatic brain injury. 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 Nuedexta to treat your personal history of traumatic brain injury. 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 Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide EC 3 milligram tablet three times per day to treat collagenous colitis. 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.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. We received the prescriber statement and included it in our review. However, we did not receive medical records.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: Favorable

At issue is coverage for Nuedexta 20-10 milligram capsules prescribed for pseudobulbar affect. The Part D plan denied coverage because the documentation did not include test results (center of neurology study-lability scale).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 part D plans prior authorization requirements for coverage of Nuedexta include a diagnosis of pseudobulbar affect and diagnostic test results supporting the diagnosis of pseudobulbar affect, such as results from a center of neurology study-lability scale. The medical records submitted at reconsideration include progress notes from office visits that show the enrollee is being treated for posttraumatic seizure disorder, post-concussion syndrome, disorientation, irritability and anger, myoclonic jerks, emotional lability, and pseudobulbar affect. Also submitted at reconsideration are results from a center of neurology study-lability scale performed on the enrollee on April 16, 2021. The results show that the enrollees total score was 32. As noted on the test form, a score of 13 or higher may suggest pseudobulbar affect.Therefore, the medical records submitted at reconsideration show that the prior authorization requirements for coverage of the medication have been satisfied. A physician reviewed the appeal and determined that the plan is required to cover the Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz 5-milligram tablet to treat oral lichen planus. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.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 Morphine Sulfate 30-milligram tablet three-times-daily to treat cervical spondylosis pain. 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 plan limits the amount of daily opioids on hand at 200-milligrams or more morphine equivalents-per-day. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 2 milligram sublingual tab prescribed for opioid abuse and chronic pain syndrome. 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 physician submitted a statement that the drug was prescribed for opioid abuse and chronic pain syndrome. However, there are no medical records submitted to support the diagnosis.  The documentation does not satisfy 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

At issue is Ocrevus intravenous solution to treat progressive multiple sclerosis. 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 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 Ocrevus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Relistor 12 milligram/0.6 milliliter solution prescribed for irritable bowel syndrome with constipation. 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 your condition. However, 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 requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathioprine 50-milligram tablet to treat sarcoidosis. 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.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 Levalbuterol Tartrate 45 microgram inhalation solution prescribed as directed for shortness of breath. 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 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 these conditions. 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 Levalbuterol Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligram tablets prescribed daily for cerebral vasculitis and central nervous system vasculitis. 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 Mycophenolate Mofetil to treat your cerebral vasculitis and central nervous system vasculitis. 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% Patch prescribed for bilateral primary osteoarthritis of the knees. 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 information submitted at the reconsideration level. Your physician states he prescribed Lidocaine Patch for your osteoarthritis. 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, the documentation does not satisfy the plans coverage criteria. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lo Loestrine FE 1-10 tablet prescribed for birth control. 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 drug requested is not on the plans formulary. The medical records do not specifically address each formulary alternative and why they did not or would not work. A physician reviewed your appeal and determined that the plan is not required to cover Lo Loestrine FE 1-10 tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Avastin intravenous infusion prescribed as directed to treat hepatocellular carcinoma. 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 available.The record shows the enrollee was prescribed Avastin intravenous infusion for the treatment of hepatocellular carcinoma. However, this drug is eligible for coverage under Medicare Part B. Chemotherapy drugs administered via intravenous infusion are eligible for coverage under Medicare Part B. Therefore, the requested drug is not eligible for coverage under Medicare Part D. We determined that the plan is not required to cover Avastin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tecentriq intravenous infusion prescribed as directed to treat hepatocellular carcinoma. 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 available.The record shows the enrollee was prescribed Tecentriq intravenous infusion for the treatment of hepatocellular carcinoma. However, this drug is eligible for coverage under Medicare Part B. Chemotherapy drugs administered via intravenous infusion are eligible for coverage under Medicare Part B. Therefore, the requested drug is not eligible for coverage under Medicare Part D. We determined that the plan is not required to cover Tecentriq.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron 4 milligram oral tablet disintegrating prescribed daily for nausea and vomiting. 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 asked your 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 did not receive the documentation requested.Your medical records show your doctor prescribed Ondansetron to treat your nausea vomiting. However, the Medicare approved compendia do not support the use of this drug for your condition. As such, 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.A physician reviewed your appeal and determined that the plan is not required to cover Ondansetron.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Esomeprazole Magnesium 20 milligram 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. We asked the prescriber to send us a prescriber statement and medical records to show why the enrollee needs this medication. We did not receive the documentation requested.Esomeprazole Magnesium is a generic drug on Tier 4 of the plans formulary. The documentation available for review does not include a prescriber statement or medical records. 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.