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

At issue is Freestyle Libre 14 Day Sensor prescribed for diabetes. 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.Supplies for testing and monitoring blood glucose levels are not considered Part D drugs and may be covered under the Medicare Part B Durable Medical Equipment benefit.A physician reviewed your appeal and determined that the requested diabetic equipment is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira (CF) Pen 40 milligrams/0.4 milliliter, 6 for 42 days to treat your condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The plan limits the amount of Humira (CF) Pen 40 milligrams/0.4 milliliter provided to a 30 day supply. 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 Levalbuterol .63 milligram/3 milliliter nebulizer solution prescribed for bronchitis. The Part D plan denied the request because the drug was not used for 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 record shows Levalbuterol is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Levalbuterol. Please consider submitting this request to Medicare Part B. 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

At issue is a tiering exception request for Modafinil 200 milligram oral tablet prescribed daily for excessive daytime sleepiness from obstructive sleep apnea. 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 information submitted at the reconsideration level.Modafinil 200 milligram oral tablets is a generic drug on Tier 3 of the plans formulary. There are no generic 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Firazyr 30 milligram/3 milliliter solution prescribed for acquired angioedema. 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 Firazyr for acquired angioedema. 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

You requested Brovana 15 microgram/2 milliliter nebulizer solution prescribed for chronic obstructive pulmonary disease. 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 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. The records show you prescribed Brovana to treat the enrollees chronic obstructive pulmonary disease. The Medicare approved compendia do support the use of this drug for this condition. However, we determined that the plan is not required to cover Brovana because it is eligible for coverage under Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone Hydrochoride 30 milligram tablets, 90 tablets per 30 days, to treat chronic pain. The Part D plan denied the request because quantity limit 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 information submitted at the reconsideration level.The prescriber indicated that the accumulated morphine milligram equivalent warranted to treat the enrollee's pain is 270 milligrams/day. The accumulated morphine milligram equivalent of one or more of the enrollee's opioid prescriptions is 360 milligrams/day. 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

You requested Diclofenac Sodium 1% gel prescribed for spondylosis without myelopathy or radiculopathy, lumbar region. 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 Diclofenac Sodium for your spondylosis, lumbar region. 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 Rinvoq 15 milligram tablet prescribed for the enrollees rheumatoid arthritis. 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 rheumatoid arthritis. 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: Unfavorable

At issue is Armodafinil 150 milligram tablets to treat fatigue related to multiple sclerosis. 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 record shows the requested drug was being prescribed to treat the provided diagnosis. 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 enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 tablets 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 Azathioprine to prevent rejection following a kidney transplant. The Medicare approved compendia support the use of this drug for your condition. Based on the information provided, the drug is eligible for Part B coverage.  Therefore, the drug is not eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is not required to cover Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Gel 1% to treat male hypogonadism.   The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The initial diagnosis provided was unspecified endocrine disorder.  The prescriber clarified the diagnosis and provided laboratory values with the request for reconsideration. The documentation does not satisfy the Plans coverage criteria. Testosterone replacement therapy requires a diagnosis of primary or hypogonadotropic hypogonadism to satisfy Prior Authorization criteria. Approved compendia note that  The safety and efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism.   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 Lidocaine 5% patch prescribed for pain in left knee and other chronic 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 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 Lidocaine patch for pain in left knee and chronic pain. 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 Ipratropium-Albuterol 0.5-3 milligram/3 ampule via nebulizer to treat chronic obstructive pulmonary disease. 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 Ipratropium-Albuterol is being administered to you via a nebulizer and there is no indication that you are residing in a skilled nursing facility/ long-term care facility. The Social Security Act states that a drug prescribed to a Part D eligible individual cannot be considered a covered Part D drug if payment for the drug is or would be available under Medicare Part A or Part B. Medicare covers drugs that use durable medical equipment, such as drugs given by a nebulizer, under the Part B benefit and not the Part D benefit.As such, our decision is that the Part D plan is not required to cover Ipratropium-Albuterol. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cresemba 186 milligram capsule prescribed for prophylaxis against invasive aspergillosis. The Part D plan denied your request because your prescriber did not address alternative medications were tried and failed. 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 Cresemba for prophylaxis against invasive aspergillosis. 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

You requested Dipyridamole 75 milligram tablets prescribed as directed for other disorders of phosphorous metabolism. 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 documentation shows the prescriber ordered Dipyridamole to treat other disorders of phosphorous metabolism. 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 Dipyridamole.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium Bromide 0.02 percent solution via nebulizer to treat asthma. 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 Ipratropium Bromide is being administered to you via a nebulizer and there is no indication that you are residing in a skilled nursing facility/ long-term care facility. The Social Security Act states that a drug prescribed to a Part D eligible individual cannot be considered a covered Part D drug if payment for the drug is or would be available under Medicare Part A or Part B. Medicare covers drugs that use durable medical equipment, such as drugs given by a nebulizer, under the Part B benefit and not the Part D benefit.As such, our decision is that the Part D plan is not required to cover Ipratropium Bromide. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dextroamphetamine/amphetamine 20 milligram tablets prescribed as directed for other specified behavioral and emotional disorder (F98.8). 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 prescriber submitted prior authorization form with the diagnosis of other specified behavioral and emotional disorder (F98.8). 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 Dextroamphetamine/amphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus SoloStar pen 100 units/milliliter prescribed as directed for uncontrolled type II diabetes mellitus. 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. Lantus SoloStar pen 100 units/milliliter is a biologic on Tier 3 of the plans formulary. The prescriber statement shows you were prescribed Lantus SoloStar pen 100 units/milliliter for uncontrolled type II diabetes mellitus. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Lantus SoloStar pen 100 units/milliliter because there are no brand drugs of the same type on the lower cost sharing tiers
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Austedo 12 milligram tablets prescribed twice daily for the enrollees tardive dyskinesia. 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 tardive dyskinesia. 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: Unfavorable

You requested Dronabinol 5 milligram capsules prescribed to prevent vomiting due to acute upper gastrointestinal bleeds, gastric bypass surgery, and acute weight loss. The Part D plan denied your request 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.We determined that the plan is not required to cover Dronabinol because it was prescribed to treat weight loss. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hizentra 10 grams/50 milliliter injection for primary immunodeficiency and common variable immunodeficiency with predominant abnormalities of B-cell numbers and function. 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.The record shows your doctor prescribed the medication for primary immunodeficiency and common variable immunodeficiency with predominant abnormalities of B-cell numbers and function. The drug is to be infused through an external infusion pump. This drug is eligible for coverage under Medicare Part B. Medicare Part D does not cover intravenous immunoglobulin in the enrollees home.We determined that the plan is not required to cover Hizentra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine 8 milligram sublingual tablet prescribed every 12 hours for chronic pain syndrome. The Part D plan denied the drug because it was not medically necessary. The plan requires prior approval before covering some 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 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.Buprenorphine 8 milligram sublingual tablet is being requested to treat chronic pain syndrome. The Medicare approved compendia do not support the use of this drug formulation for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover the Buprenorphine 8 milligram sublingual tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Onetouch Ultra Test Strips. 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.Onetouch Ultra Test Strips are medical supplies not directly related to the delivery of insulin to the body and would be eligible for coverage under Medicare Part B rules. Therefore, the Medicare Part D Prescription Drug benefit is not required to cover these medical supplies.