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

At issue is Amphetamine/Dextroamphetamine 20 milligram tablet prescribed for attention deficit hyperactivity disorder. The Part D plan denied a request for coverage because the quantity of 120 tablets per 30 days exceeds the plan number allowed. We received a reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows Amphetamine/Dextroamphetamine was prescribed to treat attention deficit hyperactivity disorder. The prescriber was asked to indicate why the 80 milligram per day dose was warranted to adequately manage the enrollee's condition or to potentially have on-hand (at their disposal). The prescriber statement indicates that the enrollee has been on the medication and needs to continue. However, the Medicare approved compendia does not support the use of this specific drug dosage for the enrollees condition(s).A physician reviewed your appeal and determined that the plan is not required to cover Amphetamine/Dextroamphetamine at a quantity of 120 tablets per 30 days.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prednisone 2.5 milligrams prescribed daily for transplant immunosuppression. 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 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 record shows Prednisone was prescribed to treat transplant immunosuppression. The enrollee received a kidney transplant August 19, 1995, due to end-stage renal disease. The enrollee did have Medicare coverage at this time; however, the enrollee also was covered under private insurance. The records do not show that Medicare covered the transplant. Therefore, this drug is not eligible for coverage under Medicare Part D. We determined that the plan is not required to cover Prednisone under the Medicare Part D Prescription Drug benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sodium Chloride Solution 0.9% 43200 milliliters per 90 days prescribed 240 milliliters twice daily for irrigation. The Part D plan denied your request because the drug was excluded from coverage under Medicare Part D because it is a biologic drug, and its manufacturer has not signed the Medicare Coverage Gap Discount Agreement. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows that your doctor prescribed Sodium Chloride Solution for irrigation. No additional documentation was requested from the prescriber.We determined that the plan is not required to cover the Sodium Chloride Solution. Medicare does not allow Part D drug plans to cover drugs produced by a manufacturer that does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. Records show that the manufacturer, ICU Medical, Incorporated, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, the Part D plan is not required to cover the Sodium Chloride Solution. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tafinlar 75 milligrams daily for pancreatic cancer. The Part D plan denied your request because your condition is not a medically accepted indication for coverage of Tafinlar. 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 records show your doctor prescribed Tafinlar to treat pancreatic cancer. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the medically accepted indication requirements have not been met. A physician reviewed your appeal and determined that the plan is not required to cover Tafinlar 75 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mektovi 15 milligrams to be given three tablets every 12 hours for malignant neoplasm of the pancreas. The Part D plan denied coverage because the prior authorization requirements were not met. 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.Mektovi is being requested to treat your malignant neoplasm of the pancreas. However, the Medicare approved compendia do not support the use of this drug for your condition. This does not support a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Mektovi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil to treat Paranoid Schizophrenia  medication induced fatigue. 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 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 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 the enrollees condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rytary ER, 61.25 / 245 milligram capsules, prescribed for Parkinsons disease. The Part D Plan denied your request for a tiering exception because there were no other brand drugs appropriate to treat Parkinsons disease on a lower cost-sharing tier. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. A physician reviewed your appeal and determined that the plan is not required to cover the Rytary at a lower cost tier.Rytary is a brand name drug on Tier 4 of the plans formulary. There are no brand name drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lyrica 50 milligrams prescribed three time daily for cervical and lumbar radiculopathy. The Part D plan denied your request because the medication is 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 record shows you prescribed Lyrica 50 milligrams to treat the enrollees radiculopathy. 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 Lyrica 50 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucala 100 milligrams/milliliter injection prescribed every four weeks for severe asthma. 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. Your physician submitted a supporting statement and medical records. The medical records show the physician had prescribed Nucala to treat your severe asthma. The Medicare approved compendia does support the use of the requested drug for your condition.However, the records do not show why you cannot take other drugs on your plans formulary for your condition. Specifically, Fasenra was not tried and there was not medical documentation to support why it could not be considered and tried.A physician reviewed your appeal and determined that the plan is not required to cover Nucala. Nucala is not in your plans formulary and there is no indication that all drugs to treat your condition have been tried and failed.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amphetamine- Dextroamphetamine Tablet 20 MG to treat major depressive disorder.  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 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 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 the enrollees condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Cimzia Starter Kit 400 milligrams per 2 milliliter subcutaneous syringe kit prescribed for rheumatoid arthritis. The Part D plan denied your request for a formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Cimzia to treat your rheumatoid arthritis. The Medicare approved compendia support the use of this drug for your condition. Your doctor submitted a prescriber statement indicating that you tried Orencia, Enbrel, Humira, and Simponi Aria. These drugs did not improve your condition. However, the plan formulary includes other drugs that could be used to treat your condition. Your records do not show that all alternative drugs on the plan formulary have been tried or why the risk is too high and you must not take them. This decision does not address the medical necessity of the requested drug. It only means that it cannot grant a formulary exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aubagio 14 milligrams prescribed as directed for multiple sclerosis. 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. 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 Aubagio 14 milligrams to treat your multiple sclerosis. The Medicare approved compendium supports the use of this drug to treat your condition. 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 Aubagio because your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prevymis 480 milligrams prescribed daily for recurrent cytomegalovirus infection in a seronegative heart transplant recipient. The Part D plan denied your request because the medication 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 medical records show you prescribed Prevymis to treat the enrollees recurrent cytomegalovirus infection following a heart transplant. The records indicate that valganciclovir and ganciclovir were tried and caused profound neutropenia. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Prevymis 480 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Benzonatate 100 milligrams prescribed daily for the enrollees condition. The Part D plan denied your request because cough and cold medications do not meet the definition of Part D drugs. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Benzonatate because it it was for the symptomatic relief of coughs and colds. Drugs prescribed for symptomatic relief of cough and colds 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 Hydromorphone/Bupivacaine syringe to be infused via an intrathecal pump to treat chronic pain. 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.Based on the information provided, we determined the drug would be eligible for coverage under Part B. 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 a tiering exception request for Travatan Z 0.004%, 2.5 milliliter per 20 days to treat the enrollee's 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 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.Travatan Z 0.004% is a non-formulary drug  and is therefore 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 Synthroid to treat the enrollee's 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 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.Synthroid is a brand drug on Tier 3 of the plans formulary. The prescriber has not indicated that the enrollee has tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective for the enrollee 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

You requested Lantus Solostar 100 units/milliliter prescribed 70 units twice daily for diabetes. The Part D plan denied your request because there was no reason given to approve an amount above quantity limit criteria. 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 shows your doctor prescribed you to take 70 units of Lantus Solostar twice daily. The prescription supports you are to take 140 units a day. The plan approved nine milliliters or 900 units for a six day period. Your doctor prescribed you to take 840 units over a six day period. Therefore, the plan has approved an amount greater than your doctor prescribed. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover the requested quantity of nine milliliters for three days.A physician reviewed your appeal and determined that the plan is not required to cover the Lantus Solostar, 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 Armodafinil 200 milligram tablets prescribed as directed for an unspecified disorder of adult personality and behavior. 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 medical records show the doctor prescribed Armodafinil to treat an unspecified disorder of adult personality and behavior. The physician states the enrollees disorder is characterized by low energy, difficulties with concentration, excessive sleepiness, fatigue, and depression. However, the Medicare approved compendia do not support the use of Armodafinil for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipratropium-Albuterol nebulized solution prescribed every six hours as needed for amyotrophic lateral sclerosis and obstructive sleep apnea. 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 Ipratropium-Albuterol nebulized solution to treat the enrollees amyotrophic lateral sclerosis and obstructive sleep apnea. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed your appeal and determined that the plan is not required to cover Ipratropium-Albuterol nebulized solution. It is also noted that nebulized solutions used in conjunction with a nebulizer for in-home use are covered under Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta 50 milligram tablets prescribed twice daily for the enrollees rheumatoid arthritis related pain. 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 enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan would likely cause harm or not be as effective for the enrollee as the requested drug. 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 a tiering exception request for Restasis to treat the enrollee's 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 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.Restaisis is a brand drug on Tier 2 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 Clobetasol propionate 0.05%-niacinamide 4% cream prescribed as directed. The Part D plan denied your request because Clobetasol propionate-niacinamide has not been proven safe and effective by the Food and Drug Administration. We received an 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. We determined that the plan is not required to cover Clobetasol propionate-niacinamide because it has not been approved by the Food and Drug Administration. Drugs that have not been approved by the Food and Drug Administration 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.