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

You requested coverage for NuvaRing 0-12-0.15 milligrams per 24 hours. The Part D plan denied your request because the medication was being used for a non-medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation supports that the NuvaRing has been prescribed to treat dysmenorrhea associated with endometriosis. 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

You requested Forteo 620 microgram/2.48 milliliters injection prescribed for osteoporosis. The Part D plan denied coverage because guideline rules for the requested drug were not met. 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. The documentation is insufficient to determine if the enrollees diagnosis meets the requirements for medical necessity and prior authorization. A physician reviewed your appeal and determined that the plan is not required to cover Forteo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amitiza 24 microgram capsules. 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 documentation did not contain a supporting statement from your doctor to address if you had tried and failed all formulary alternatives. A request for medical records and a supporting statement was sent to your doctor. No documentation was received. The submitted documentation does not contain medical records to support a prescribed diagnosis for the drug at issue. As it cannot be determined the drug was 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 Amitiza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Febuxostat 40 milligram tablet prescribed as directed for an unknown 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 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 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 step therapy 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 Prolia 60 milligrams/milliliter injection to treat osteoporosis. The Part D plan denied your request for a tiering exception. We received an expedited 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. Prolia is a biologic drug on Tier 4 of the plans formulary. There are no biologic drugs of the same type on the lower cost sharing tiers. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets for anticoagulation in an enrollee with nonvalvular atrial fibrillation.   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 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 Lovaza 1 gram capsules prescribed daily for mixed hyperlipidemia. The Part D plan denied your request because the provide diagnosis does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Lovaza to treat your mixed hyperlipidemia. 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 Lovaza because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Lidocaine 5% patches. 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. The documentation indicates that Lidocaine patches are being prescribed for osteoarthritis. 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 condition. 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 Lidocaine patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nulojix 250 milligram solution prescribed for kidney transplant. The Part D plan denied the request because the enrollees transplant was in a Medicare approved facility covered by Part A. Therefore, anti-rejection drugs are covered under Part B. 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 determined that the plan is not required to cover the Nulojix. Medicare records indicate the enrollee received a kidney transplant on October 30, 2019, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Nulojix is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. Please submit your request to Medicare Part B. 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 Nasonex 50 microgram nasal spray prescribed as directed for allergic rhinitis. The Part D plan denied your request for a tiering exception. We received an expedited 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. Nasonex is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Buprenorphine 10 microgram per hour weekly patches. The Part D plan denied your request because the medication was not included on the plans formulary and 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 documentation supports that Buprenorphine patches have been prescribed to treat the enrollees chronic pain syndrome as a result of intervertebral disc displacement, lumbar region. However, the prescriber has not sufficiently addressed why all alternative drugs required by the plan to treat this condition have been tried and failed or would likely not be as effective as the requested drug or would likely cause adverse reactions or other harm. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz 5 milligrams prescribed as directed to treat seronegative rheumatoid arthritis. 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 Xeljanz 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 the Xeljanz because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyndamax 61 milligram capsules prescribed daily for the enrollees heart failure and cardiomyopathy, wild type. 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 the enrollees diagnosis of heart failure and cardiomyopathy, wild type. However, the enrollee does not satisfy the plan's prior authorization coverage criteria which are reviewed by Medicare.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mupirocin 2 percent ointment prescribed as directed for chronic pansinusitis. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request.  We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Mupirocin 2 percent ointment to treat your chronic pansinusitis. 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 Mupirocin because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Orencia 125 milligram/milliliter auto-injector pen prescribed as directed to treat rheumatoid arthritis. 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 from the plan.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 the Orencia 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 the Orencia because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nulojix 5 milligram solution prescribed daily following a kidney transplant. 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 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 also researched Medicare systems and reviewed the enrollment data available. Your records show your doctor prescribed Nulojix to prevent rejection following a kidney transplant. The Medicare approved compendia support the use of this drug for your condition. The Medicare Part B rules state that parenteral Belatacept (Nulojix) is not proven to be safe when administered in the home setting, and therefore will be denied under Medicare Part B as not medically necessary when provided in that setting. The case record indicates that Nulojix will be administered in the home. Nulojix would therefore not be eligible for coverage under Medicare Part B in this case. Thus, Nulojix may be eligible for coverage under Medicare Part D. Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. Your physician has indicated that for you it is safe for Nulojix to be administered in your home. Therefore, our decision is the Plan is required to cover Nulojix 250 mg.  A physician reviewed your appeal and determined that the plan is required to cover Nulojix based on the available documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 microgram inhaler prescribed as directed for chronic obstructive pulmonary disease. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an auto-forwarded 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 that your doctor prescribed Anoro Ellipta to treat your chronic obstructive pulmonary disease. However, 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 the Anoro Ellipta because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cabometyx 20 milligrams prescribed as directed for hepatocellular carcinoma. The Part D plan denied your request because the quantity limit requested is higher than what the plan allows. We received an expedited auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. 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 quantity limit criteria. We did not receive the documentation requested.Your medical records show your doctor prescribed Cabometyx to treat your condition. The amount you were prescribed exceeds the plans number of doses that may be dispensed. There was no supporting evidence submitted to show why you require this amount. Therefore, an exception to the amount of drug requested cannot be made as the limit criteria was not met. A physician reviewed your appeal and determined that the plan is not required to cover the Cabometyx as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil 20 milligram tablets prescribed for adult pulmonary Langerhans cell histiocytosis. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Sildenafil for adult pulmonary Langerhans cell histiocytosis. 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 provided.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tadalafil 20 milligrams, two capsules to be given once a day for pulmonary artery hypertension. 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 records submitted at the reconsideration level.Tadalafil is being requested to treat the enrollees condition. The Medicare approved compendium supports the use of this drug for this condition. The plan denied the request stating the drug Isosorbide Mononitrate was currently being covered and may have a serious interaction with the requested drug. The prescriber submitted a statement and records showing the drug was discontinued prior to the initiation of Tadalafil. The plan's prior approval criteria have been satisfied. A physician reviewed your appeal and determined that the plan is required to cover the Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lioresal 500 microgram/20 milliliters dispensed by an internal pump prescribed for multiple sclerosis. 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 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. We determined that the drug is not eligible for Part B coverage. Drugs administered by an implantable infusion pump are covered by Part B. 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 Lioresal. You may wish to submit a request for Lioresal to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gammaplex 20 gram/200 milliliter injection prescribed for autoimmune encephalitis. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Gammaplex for autoimmune encephalitis. 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 Olmesartan/Amlodipine/HCTZ tablets to treat hypertension. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation 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. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.