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

At issue is Nuzyra 150 milligrams taken as 3 tablets for two days and then two tablets daily for the diagnosis of Methicillin-resistant Staphylococcus aureus infection of the left prosthetic hip and osteomyelitis of the left hip. The Part D plan denied your request because the drug at issue is not approved for these conditions. 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 regulations and Medicare approved compendia. The prescriber submitted a statement that there is no other long-term oral options other than Omadacyclinc. However, Medicare approved compendia do not support the use of this drug for the conditions reported. Medicare requires that the drug must be prescribed for a medically accepted indication that is approved by the FDA or supported by one or more citations in Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Nuzyra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Cyanocobalamin Solution 1000 micrograms per milliliter prescribed daily for symptomatic anemia. The Part D plan denied your request because the medication is excluded from coverage. 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 Cyanocobalamin Solution, which is a prescription vitamin and excluded under the Part D benefit.This decision does not address the medical necessity of the requested drug. It only means that it cannot be covered under Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Forteo 600 mcg/2.4 ml pen, 7.2 ml for 90 days prescribed for osteoporosis, unspecified. 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records included a DEXA scan from date of service 12/3/2020 which documented osteopenia, with a left femur T-score of -1.8.  The Medicare approved compendia do not support the use of this drug for your condition, osteopenia. A physician reviewed your appeal and determined that the plan is not required to cover Forteo. The drug was not prescribed for a medically accepted indication. The plan requires a diagnosis of primary or hypogonadal osteoporosis or glucocorticoid-induced osteoporosis for the use of this drug. The medical records submitted do not show that you have a medically accepted indication for the use of this drug. 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: Favorable

At issue is Vyndamax 61 milligrams prescribed for the enrollees benign cardiac amyloidosis. 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 satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee has met prior authorization criteria.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Vyndaqel 20 milligrams prescribed for the enrollees benign cardiac amyloidosis. 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 satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee has met prior authorization criteria.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
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 Mycophenolate Mofetil 250 milligram tablets prescribed following a lung transplant. The Part D plan denied your request because the drug was prescribed for a non-medically accepted indication. We received an auto-forwarded reconsideration request from the plan. 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.Your medical records show your doctor prescribed Mycophenolate Mofetil following your lung transplant for immunosuppressive therapy. However, 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trazadone 150 milligram tablets prescribed daily at bedtime. Initially, a diagnosis of schizoaffective disorder, bipolar type was used. At redetermination, a diagnosis of post-traumatic stress disorder was used. The Part D plan denied the request stating that the provided diagnoses are not medically accepted indications. 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. At reconsideration, a diagnosis of chronic insomnia is being used. No medical records have been provided to support this change in diagnosis. The dosage requested is not the typical dosage used for this indication. It cannot be determined if the drug is being used for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligram/2 milliliter syringe prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for 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.Dupixent is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier 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 Stivarga 40 milligrams,  four tablets daily prescribed for metastatic urethral adenocarcinoma.  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 Stivarga for metastatic urethral adenocarcinoma.The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Toviaz 8 milligrams to treat urinary incontinence. 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.Toviaz 8 milligrams is a brand drug on Tier 4 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

At issue is Benzonatate 200 milligram capsules to treat a cough. We received an expedited auto-forwarded reconsideration request from the Part D 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.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

At issue is Xpovio 20 milligrams prescribed for 80 milligrams twice weekly for the enrollees Multiple Myeloma. The Part D plan denied coverage because medical necessity was not established. The plan requires meeting prior authorization criteria 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 medical records do not show that the plan's coverage criteria for Xpovio are met. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated that the enrollee has tried at least two immunomodulatory agents.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 Venclexta 100 milligram tablets prescribed as four tablets daily for light chain amyloidosis. 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 medical records show the doctor prescribed Venclexta to treat light chain amyloidosis. A journal article was also submitted for review. However, the Medicare approved compendia do not support the use of Venclexta for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Venclexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fanapt 10 milligram tablets (60/30) prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for a lower cost-sharing tier. 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.Fanapt is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier 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 Buprenorphine HCl 2 milligram sublingual tablets prescribed for chronic pain syndrome and opioid dependence. 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 prescriber initially provided the diagnosis of chronic pain syndrome.  In the request for reconsideration, the prescriber changed the diagnosis to opioid dependence.  Recent medical records from date of service 2/2/2021 were provided which documented that the requested drug is being used for the treatment of Chronic pain syndrome.  The office notes provided do not support a diagnosis of opioid dependence.  The use of the requested drug to treat chronic pain syndrome 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

At issue is Jardiance 10 milligrams prescribed daily for type 2 diabetes with chronic kidney disease. The Part D Plan denied your request for a tiering exception because there are no lower tier alternatives for the enrollees condition. 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. Jardiance 10 milligrams is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. 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

You requested Letermovir 480 milligram tablets prescribed daily for prevention of cytomegalovirus following a lung transplant. 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. Your medical records show your doctor prescribed the requested drug to prevent cytomegalovirus following a lung transplant. However, 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Braftovi 75 milligram capsules prescribed metastatic prostate carcinoma with BRAF L597Q mutation. 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 records show you prescribed Braftovi to treat the enrollees metastatic prostate carcinoma. 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 Braftovi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligrams prescribed as directed for overactive bladder. 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. Myrbetriq 50 milligrams is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. 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 Myrbetriq 50 milligrams because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gralise ER 600 milligrams prescribed six times daily for chronic pain syndrome. The Part D plan denied your request because the National Drug Code for this drug wasnt registered with 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.Gralise ER is ordered to treat the enrollees chronic pain syndrome. The Food and Drug Administration website shows the National Drug Code for this drug is valid. 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 Gralise ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trintellix 20 milligram tablet prescribed for major depression disorder. The Part D plan denied your request for a tiering exception because Trintellix is a Tier 3 medication with no alternate drugs on a lower tier. We received an expedited auto-forwarded reconsideration request from the plan. 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 documentation shows Trintellix is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type for treating the enrollees condition 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 Trintellix.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% cream prescribed for anesthesia of skin. 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. Your medical records show your doctor prescribed the requested drug for anesthesia of skin. However, 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Folic acid 1 milligram prescribed as directed for folate deficiency anemia. The Part D plan denied your request because the requested drug is a prescription vitamin. 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. We also researched Medicare systems and reviewed the enrollment data available. We determined that the plan is not required to cover Folic acid 1 milligram because it is a prescription vitamin and mineral product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations 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.