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

At issue is a tiering exception request for Omega 3-Acid Ethyl Esters 1 milligram capsule to treat the enrollees condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent an 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 Opsumit tab 10 milligrams prescribed daily for pulmonary hypertension. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. A physicians statement and medical documentation was requested but was not received. Medicare approved compendia supports 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. A physician reviewed your appeal and determined that the plan is not required to cover Opsumit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Donnatal 16.2 milligrams to treat irritable bowel syndrome. 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.The plan denied the request for coverage of the requested drug to treat the provided diagnosis because your plan's Medicare Part D drug plan cannot cover drugs classified as being part of the Food and Drug Administration (FDA)'s Drug Efficacy Study Implementation (DESI) program. These drugs are considered to be Less than Effective (LTE) per Food and Drug Administration review.A physician reviewed your appeal and determined that the plan is not required to cover Donnatal.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% ointment, 35.44 grams for 20 days prescribed for synucleninopathy and demyelinating axonal neuropathy. 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 initially provided the diagnosis of synucleninopathy. In the request for reconsideration, the prescriber changed the diagnosis to demyelinating axonal neuropathy. The use of the requested drug to treat your condition 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. 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 Herpes Zoster vaccine. The Part D plan did not complete a timely coverage determination. We received an auto-forwarded reconsideration request from the coverage level. 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 you received a Herpes Zoster vaccination and are submitting a claim for direct member reimbursement. A request for medical records was submitted to your doctor. No medical records were submitted with the claim. Therefore, it cannot be determined the vaccination was prescribed for a medically accepted indication. As the vaccine 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 reimburse the requested vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested NP Thyroid 90 milligram oral tablets prescribed once a week for three weeks for hypothyroidism. The Part D plan denied your request because the drug is excluded from coverage as it is not approved by the Food and Drug Administration. 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 NP Thyroid because it is not listed as a Food and Drug Administration approved drug. 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 Buprenorphine hydrochloride 2 milligram sublingual tablets prescribed as directed for chronic pain syndrome. 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 doctor prescribed Buprenorphine hydrochloride sublingual tablets for chronic pain syndrome related to multiple sclerosis. However, the Medicare approved compendia do not support the use of this drug in sublingual form for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Multaq 400 milligram oral tablets prescribed twice daily to treat coronary artery disease with associated atrial flutter. The Part D Plan denied your request for a tiering exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Multaq is a brand drug on Tier 4 of the plans formulary. 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 grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram pen prescribed for the enrollees hyperlipidemia with atherosclerotic cardiovascular disease. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of hyperlipidemia with atherosclerotic cardiovascular disease. 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 Cinacalcet Hydrochloride 30 milligrams daily to treat secondary hyperparathyroidism. The Part D Plan denied the request because prior authorization requirements were not met. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The records show the enrollee does not satisfy the Plan's coverage criteria. The prescriber statement does not support the plans prior authorization requirements. A physician reviewed your appeal and determined that Cinacalcet Hydrochloride is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac sodium 1 percent gel prescribed for chronic pain due to chronic inflammatory demyelinating polyneuropathy. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Diclofenac sodium 1 percent gel to treat chronic pain due to chronic inflammatory demyelinating polyneuropathy. 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 Diclofenac sodium 1 percent gel because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 5 milligrams to treat neuropathic pain.  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.A physician reviewed your appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Favorable

You requested Latuda 40 milligram oral tablet prescribed daily for recurrent major depressive disorder. The Part D plan denied your 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.The prescriber statement shows Latuda was prescribed to treat recurrent major depressive disorder and bipolar depression. The enrollees medical records were received and confirm this diagnosis. The Medicare approved compendia supports the use of this drug for this condition. Therefore, the requested drug is eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is required to cover Latuda.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception for Hizentra solution prescribed daily for nonfamilial hypogammaglobulinemia. 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 Hizentra for nonfamilial hypogammaglobulinemia. In review of the Medicare approved compendia, nonfamilial hypogammaglobulinemia is a medically accepted indication for Hizentra solution. However, 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. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Hizentra solution at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gammaplex solution 20 gram/200 milliliter prescribed for use with an infusion pump for the treatment of immune deficiency of immunoglobulin. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows Gammaplex is being administered to the enrollee via external infusion pump that is used in the home. According to Medicare rules, Medicare Part D cannot cover a drug that is eligible for coverage under Part B. We determined that the Medicare Part D plan is not required to cover Gammaplex. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aptiom (Eslicarbazepine Acetate) 800 milligram tablets prescribed daily for refractory epilepsy. The Part D plan denied your request for a tiering exception. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Aptiom is a brand name Tier 4 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vascepa, 1 gram capsules. The Part D plan denied coverage because the diagnosis provided was not Food and Drug Administration-approved or supported by one of the Medicare-approved medical references. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records requested and submitted at the reconsideration level. The submitted documentation shows that the drug was prescribed to treat hypertriglyceridemia. The Medicare approved compendia does include severe hypertriglyceridemia, defined as a triglyceride levels greater than 500 milligrams per deciliter, as a medically acceptable indication for the use of Vascepa. However, the submitted documentation does not validate that the enrollee had a pre-treatment triglyceride level of greater than 500 milligrams per deciliter. Therefore, there is insufficient information to determine if the drug is being prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover the Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dapsone 25 milligram tablets prescribed for dermatitis herpetiformis. The Part D Plan denied your request for a tiering exception because the submitted documentation did not explain why the plans alternative drugs in lower tiers would not work just as well. 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. Dapsone 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.Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benzonatate 100 milligram capsule prescribed as directed for cough. 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.Drugs prescribed for the symptomatic treatment of cough and colds are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium Gel prescribed for low back pain and dorsalgia. The Part D plan denied your 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. Your medical records show your doctor prescribed Diclofenac Sodium Gel to treat your low back pain and dorsalgia. However, the Medicare approved compendia does 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 Diclofenac Sodium Gel. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Accu-Chek Aviva Plus test strips to check blood glucose levels. The Part D plan denied your request to cover the item under Part D. 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 other information submitted at the reconsideration level.The record shows that your doctor prescribed Accu-Chek Aviva Plus test strips to check blood glucose levels. Blood glucose testing strips are excluded from coverage under Part D. As such, our decision is that the Part D plan is not required to cover the Accu-Chek Aviva Plus test strips. This decision does not refer to the medical necessity of the requested item. It only establishes that payment cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Procrit 20,000 units subcutaneous prescribed for anemia in end stage renal disease. 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 levelThe record shows Procrit was ordered for the treatment of anemia in end state renal disease. However, this drug is eligible for coverage under Medicare Part B when used to treat anemia in enrollees not receiving dialysis.We determined that the plan is not required to cover Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ritalin LA 10 milligram tablets prescribed daily for major depressive disorder. 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 Ritalin LA for major depressive disorder. In review of the Medicare approved compendia, major depressive disorder is not a medically accepted indication for Ritalin LA. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Ritalin LA at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vemlidy 25 milligram tablets prescribed for hepatitis B and HIV infection. 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Vemlidy to treat hepatitis B and HIV infection. The Medicare approved compendia do support the use of this drug for hepatitis B with compensated liver disease.  It is not to use as monotherapy for HIV infection. The plan also requires an intolerance or contraindication to Tenofovir Disoproxil Fumarate or bone loss and mineralization defects or is at risk for bone loss and mineralization defects 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 Vemlidy.