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

You requested Tukysa 150 milligram tablets prescribed to treat metastatic breast cancer. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The record shows the enrollee was diagnosed with breast cancer in 2002, and treated with chemotherapy, radiation, and antiestrogen treatment. In 2017, the enrollee was found to have metastatic disease and treatment with Ibrance was initiated. After three years of treatment with Ibrance, the enrollee developed blurry vision and choroidal metastasis was identified. The enrollee also had extensive small foci in the brain, which was considered to be related to metastatic disease. The enrollee was treated with Avastin and radiation. Due to disease progression, Ibrance was discontinued and the enrollee began treatment with Abraxane. Molecular profiling results show the enrollee has ERBB2/HER2 mutation. Therefore, the physician is requesting treatment with Tukysa, in combination with Capecitabine and Herceptin. The Medicare approved compendia show Tukysa is indicated for the treatment of metastatic breast cancer, advanced or unresectable HER2 positive disease, in combination with Herceptin and Capecitabine in patients who have had one or more prior anti-HER2 treatments in metastatic setting. The record does not show the enrollee has had prior anti-HER2 treatments. The National Comprehensive Cancer Network guidelines show a category 2A recommendation for this regimen as a primary treatment in select patients (patients with small asymptomatic brain metastases). However, this enrollee had previous radiation therapy for metastatic disease to the brain. Therefore, the treatment regimen would not be considered a primary treatment for this enrollee. The Medicare approved compendia do not support the use of Tukysa for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Tukysa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent patch prescribed for unspecified fracture of lower end of right femur, initial encounter for closed fracture. The Part D plan denied coverage because medical necessity was not established. 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 physician states he prescribed the Lidocaine 5 percent patch for unspecified fracture of lower end of right femur, initial encounter for closed fracture. The Medicare approved compendia do not support the use of this drug, as prescribed, 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 a formulary exception for Kineret 100 milligram/0.67 milliliter solution prefilled syringe prescribed daily for gout. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 you were prescribed Kineret for gout. The Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Kineret.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram capsules prescribed twice daily for anorexia due to chronic obstructive pulmonary disease and alpha-1 antitrypsin deficiency. The Part D plan denied your 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 for weight gain. 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 a formulary exception for Cresemba 186 milligram capsules prescribed for encounter for prophylactic measures, unspecified; allogeneic hematopoietic stem cell transplant, prophylaxis for mold and aspergillosis. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 you were prescribed Cresemba for encounter for prophylactic measures, unspecified; allogeneic hematopoietic stem cell transplant, prophylaxis for mold and aspergillosis.In review of the Medicare approved compendia, encounter for prophylactic measures, unspecified; allogeneic hematopoietic stem cell transplant, prophylaxis for mold and aspergillosis is not a medically accepted indication for Cresemba. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover Cresemba at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Temazepam 30 milligram capsules prescribed daily for insomnia secondary to generalized anxiety disorder. The Part D plan denied your 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 includes a supporting statement from your doctor that indicates Temazepam was not prescribed for short-term insomnia. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that 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 the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

You requested Venclexta Starting Pack, which contains 10, 50, and 100 milligram tablets, prescribed to treat mantle cell lymphoma. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows the enrollee has mantle cell lymphoma. The enrollee was treated with Rituxan, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone, followed by maintenance Rituxan. From 2015 to 2018, the enrollee was treated with Ibrutinib. The treatment regimen was then changed to Rituxan and Revlimid. Most recently, the enrollee has been on single agent treatment with Acalabrutinib. However, imaging results showed disease progression one month ago. The provider submitted an article from the New England Journal of Medicine, a Medicare approved compendium, which supports the use of Venclexta with Ibrutinib in heavily pretreated patients with mantle cell lymphoma. Ibrutinib is a Bruton tyrosine kinase inhibitor; Acalabrutinib is also a Bruton tyrosine kinase inhibitor. The National Comprehensive Cancer Network guidelines show that both Ibrutinib and Acalabrutinib are approved to treat mantle cell lymphoma. The prescriber is requesting to use Venclexta in combination with Acalabrutinib since the enrollee experienced disease progression on Ibrutinib in the past. The Medicare approved compendia support the use of this drug for the enrollees condition. In addition, an exception to the plans prior authorization criteria is medically necessary.  A physician reviewed your appeal and determined that the plan is required to cover Venclexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Crestor 40 milligram oral tablets prescribed for coronary artery disease. The Part D plan denied your request for a tiering exception.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. This drug is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are 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 Octagam 10 grams/100 milliliters intravenous solution prescribed as directed. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The diagnosis of sarcoidosis was provided at initial coverage determination and redetermination. At reconsideration, a diagnosis of small fiber neuropathy was also given. The medical records support that the physician prescribed Octagam for the treatment of an enrollee with small fiber neuropathy related to sarcoidosis. 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 Octagam.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage and a tiering exception for Osphena 60 milligram tablets prescribed for postmenopausal atrophic vaginitis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The plan has prior authorization requirements that need to be satisfied prior to providing coverage for this drug. During this review, a request was submitted to the prescriber to address the plans coverage requirements and to provide supporting medical records. The prescriber did not reply to our request for information. Therefore, it cannot be established that the plans prior authorization criteria have been met. Additionally, since the prior authorization requirements have not been satisfied, a tiering exception for the medication cannot be granted. A physician reviewed the appeal and determined that the plan is not required to cover the Osphena.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clobazam 10 milligram tablets prescribed for localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The medical records show you prescribed Clobazam 10 milligram tablets to treat the enrollees epilepsy. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided 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 cover Clobazam 10 milligram tablets. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Octreotide 100 milligram/milliliter injectable prescribed for arteriovenous malformation, site unspecified, with lower gastrointestinal bleed. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 you were prescribed Octreotide for arteriovenous malformation, site unspecified, with lower gastrointestinal bleed.In review of the Medicare approved compendia, arteriovenous malformation, site unspecified, with lower gastrointestinal bleed is not a medically accepted indication for Octreotide. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Octreotide at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine HCL 8 milligram sublingual tablets prescribed for chronic pain syndrome. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows Buprenorphine HCL sublingual tablets were prescribed to treat chronic pain syndrome. However, the Medicare approved compendia do not support the use of this drug, as prescribed, for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine HCL sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cresemba 186 mg capsule prescribed as antifungal prophylaxis for an enrollee with acute myeloid leukemia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The records show you prescribed Cresemba 186 mg capsule as antifungal prophylaxis for an enrollee with acute myeloid leukemia. 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 Cresemba 186 mg capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Cresemba 186 milligram capsules for the prophylaxis of pulmonary aspergillosis. 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.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexlizet 180-10 milligram oral tablet prescribed for atherosclerotic heart disease of native coronary artery without angina pectoris. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to Nexlizet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Esomeprazole 40 milligram capsules prescribed for the enrollees condition. The Part D plan denied your 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.Esomeprazole is a non-formulary brand drug. Non-formulary drugs are 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

At issue is Emgality 120 milligram/1 milliliter auto-injector. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. This drug is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are 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

At issue is Cosentyx 300 milligram/2 syringes (150 milligram syringe) for moderate to severe chronic plaque psoriasis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Cosentyx to treat your chronic plaque psoriasis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided 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 cover Cosentyx. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mavyret 100/40-milligram tablets to treat Genotype 2, treatment naive, Hepatitis C with compensated cirrhosis for 12 weeks. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation provided addressed the plans coverage criteria, and those criteria were not satisfied. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.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 Albuterol Sulfate 1.25 milligrams/3 milliliter nebulizer solution prescribed for chronic bronchitis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The drug at issue is prescribed for use in a nebulizer in the enrollees home. This is eligible for coverage under Part B. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Albuterol Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humalog 100 milliliter solution vial prescribed for diabetes. The Part D plan denied your requestWe received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows Humalog is being administered through an infusion pump in the home for treatment of diabetes. Medicare law specifically excludes coverage for any drug for which payment would be available under Part A or Part B of Medicare for that individual. 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 drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover the Humalog. 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 Esomeprazole 40 milligram tablet. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition and provide a diagnosis. We also asked for medical records or other documentation to show why you need this medication. Specifically, we asked your provider to address the plans quantity limit criteria. We did not receive the documentation requested. No medical records were provided by the prescriber. 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.A physician reviewed your appeal and determined that the plan is not required to cover the Esomeprazole.