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

At issue is Omeprazole 40 milligram sodium bicarbonate, 1680 milligram oral packet prescribed as directed to treat gastroesophageal reflux disease and gastroparesis. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 record shows that your doctor prescribed Omeprazole 40 milligram sodium bicarbonate, 1680 milligram oral packet to treat your condition. Your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover Omeprazole 40 milligram sodium bicarbonate, 1680 milligram oral packet because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Visbiome 112.5 billion cell capsules to treat irritable bowel syndrome. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. The drug that is requested, Visbiome at the strength of 112.5 billion cells per capsule, is an over the counter item and is non-prescription. Non-prescription drugs are excluded from Medicare Part D drug benefits.Our Physician Reviewer determined that the plan is not required to cover Visbiome 112.5 billion cell capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ezetimibe 10 milligram tablets prescribed for pure hypercholesterolemia. The Part D Plan denied your request for a tiering exception because there were no other similar drugs on 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. A physician reviewed your appeal and determined that the plan is not required to cover the Ezetimibe at a lower cost tier.Ezetimibe is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers. If there are no generic 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 for the Ezetimibe.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Yupelri 175 micrograms/3 milliliters inhalation solution prescribed as directed for chronic obstructive pulmonary disease. You requested that the plan provide coverage for a drug that is eligible for Medicare Part B coverage. The plan did not make a decision within the required timeframe. We received an auto-forwarded reconsideration request from the plan. 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 Yupelri for chronic obstructive pulmonary disease. However, this drug is eligible for coverage under Medicare Part B. Medicare Part B covers this drug for obstructive pulmonary disease, when used with a nebulizer in the home (or in an assisted living facility). Medicare Part D cannot pay for drugs that are covered by Medicare Part B.We determined that the plan is not required to cover Yupelri.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nucala 100 milligram auto-injector pen prescribed as directed for moderate persistent asthma. The Part D plan denied the request because it 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. The medical records show the doctor prescribed Nucala auto-injector pen for your condition. 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 Nucala auto-injector pen because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sandostatin LAR depot 20 milligram kit prescribed for angiodysplasia of colon with hemorrhage related to presence of ventricular assistance device and anticoagulation. The Part D plan denied your request because the medication 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. The records show you prescribed Sandostatin LAR depot 20 milligram kit to treat the enrollees angiodysplasia of colon with hemorrhage related to presence of ventricular assistance device and anticoagulation. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Sandostatin LAR depot 20 milligram kit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 10 milligrams tablet. The Part D plan denied coverage. 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 records submitted at the reconsideration level. The physician submitted a supporting statement. The prescriber statement indicates that the physician had prescribed Cyclobenzaprine Hydrochloride for sacroiliitis and other specified disorders of muscle. However, medical records have not been submitted for review. Therefore, the documentation available does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Favorable

You requested Morphine Sulfate Extended Release 15 milligram tablets prescribed twice daily for chronic pain. The Part D plan denied your 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. Your medical records show your doctor prescribed Morphine Sulfate Extended Release to treat your chronic pain. A physician reviewed your appeal and determined that the plan is required to cover Morphine Sulfate Extended Release. Medical records and prior authorization forms submitted with the Reconsideration appeal support the prior authorization criteria has been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Orgovyx 120 milligrams to treat benign prostatic hypertrophy and prostate cancer. The Part D plan denied your request. 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 regulations and Medicare approved compendia. A request was sent to the prescriber to confirm the diagnosis and to submit medical records supporting the prostate cancer was advanced. No supporting medical records were received. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees condition. The drug is not approved by the Food and Drug Administration to treat the diagnoses submitted. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our Physicians Reviewer determined that the plan is not required to cover Orgovyx.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec ODT 75 milligrams prescribed as directed for migraines. The case was auto-forwarded by the plan. 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 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 records submitted at the reconsideration level. Your medical records show you were prescribed Nurtec ODT for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided do not show the coverage criteria has been met. The prescriber statement indicates that there has not been a trial of or contraindication to one formulary triptan. 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 Nurtec ODT.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Leflunomide 20 milligram tablets prescribed daily for rheumatoid arthritis. 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. Leflunomide is a generic drug on Tier 3 of the plans formulary. You submitted a supporting statement. The statement said Leflunomide was prescribed to treat rheumatoid arthritis. The enrollee tried and failed Methotrexate in the past. However, the plans formulary also includes Azathioprine a generic drug which is the same class as Leflunomide, on Tier 2. The record did not address why Azathioprine would not work for the enrollee. All generic drugs on lower tiers have not been tried. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% topical cream prescribed topically prior to dialysis for pain prevention. 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 the physician ordered the lidocaine cream to be used while in dialysis. According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. We determined that the plan is not required to cover the Lidocaine cream. Drugs which are eligible for Part B coverage are excluded from Part D coverage.We determined that the plan is not required to cover the Lidocaine cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Icosapent Ethyl 1 gram capsules prescribed for hyperlipidemia and atherosclerotic heart disease of native coronary artery without angina pectoris. The Part D plan denied the request stating that the provided diagnoses were not medically accepted indications for the use of Icosapent Ethyl. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Icosapent Ethyl.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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vemlidy 25 milligram tablets. The Part D plan denied coverage because the following prior authorization requirement was not met: evidence of compensated liver disease. 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 records requested and submitted at the reconsideration level. The submitted documentation shows that the drug was prescribed to treat chronic viral hepatitis B without delta-agent. However, the medical records do not support the presence of compensated liver disease. Therefore, the plans prior authorization requirement has not been satisfied. A physician reviewed your appeal and determined that the plan is not required to cover the Vemlidy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethegan 25 milligram suppositories prescribed for nausea. The Part D plan denied your request because the documentation did not support an off-formulary 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. 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 Vusion 0.25%-81.35%-15% ointment prescribed for candidiasis of skin and nails. 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 Vusion ointment for candidiasis of skin and nails. 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

Buprenorphine 8 mg SL tablet was requested to treat the enrollees condition.  The Part D plan denied your request because medical necessity was not established.  As well, the requested drug has prior authorization criteria.  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.A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  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

You requested Tacrolimus 0.5 milligram prescribed one capsule twice a day for post-transplant. The Part D Plan denied the request because the prescriber did not provide the detailed information necessary to cover this drug for a prior authorization. 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.We determined that the drug is eligible for Part B coverage. The beneficiary had a Medicare-covered transplant on July 31, 2013. Therefore, the drug can be considered for payment under the Part B benefit.A physician reviewed your appeal and determined that the plan is not required to cover.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dificid 200 milligram tablets. The Part D Plan denied the request because you were in the coverage gap of your prescription drug coverage, and payment had been effected. 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.The record shows the plan has approved payment for the drug at issue. You were in the coverage gap of your prescription drug plan. Your financial responsibility in the coverage gap for brand name drugs is 25% of the approved cost.We determined that the plan is not required to reimburse you for the Dificid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig 140 milligram/milliliter subcutaneous injection prescribed for the enrollees migraine disorder. 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 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 records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of migraine disorder. However, the enrollee does not satisfy the plan's prior authorization 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: Favorable

At issue is Everolimus 0.25-milligram tablet prescribed for transplant anti-rejection. The Part D plan denied the request because the drug is not covered under your Part D benefit (your pharmacy benefit) but they may be covered under your supplemental wrap 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 physician prescribed Everolimus for transplant anti-rejection after your liver transplant on November 5, 2018. Medicare records show you enrolled in Medicare Part A and B effective October 1, 2019, which is after the date of your transplant. A physician reviewed the appeal and determined that the plan is required to cover Everolimus because your were not enrolled in Medicare Part A and B on the date of the transplant.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 3 milligram capsules.  At initial determination and redetermination the diagnoses of non-infective gastroenteritis and colitis were given. 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.At reconsideration a diagnosis of microscopic (collagenous) colitis was given. No medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. The documentation also does not satisfy the plans coverage criteria. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Modafinil 100 milligrams tablets to treat excessive daytime fatigue due to obstructive sleep apnea.   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 clarified the diagnosis and medical history in the request for reconsideration.  Medical records were provided from date of service 1/26/2021 which substantiate the diagnosis of  excessive daytime fatigue associated with obstructive sleep apnea.  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

You requested Linezolid 600 milligram tablets prescribed for unspecified infection following a liver transplant. 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 originally prescribed Linezolid for an unspecified infection following a liver transplant. The Medicare approved compendia do not support the use of this drug for your condition. A supporting statement was received that indicated you were diagnosed with a Vancomycin-resistant enterococcus infection. However, there were no medical records submitted to support a change to this diagnosis. 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.