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

At issue is Kisqali 400 milligrams prescribed for metastatic breast cancer to lungs and pelvic bone. The Part D plan denied your request for a tier change request because Kisqali is in the specialty tier of your list of covered drugs. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The plan shows Kisqali is a brand name Tier 5 drug. Your plan does not allow you to receive drugs in this tier at a lower cost share.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 20 milligram tablet prescribed for atrial fibrillation. The Part D plan denied your request for a tiering exception because there are no lower tier alternatives of the same type for your condition. 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. Xarelto 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. There is no brand drug on a lower eligible tier of the same type that is used to treat your condition. Therefore, your plan is not required to offer you a lower cost share.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Sildenafil 20 milligram tablets three times a day to treat pulmonary arterial hypertension. 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 Sildenafil to 90 tablets per 30 days. The documentation submitted does includes medical records documenting poor response to treatment at doses lower than 40 milligrams three times daily.  Therefore, an exception to the plans coverage criteria is supported. Our physician reviewer's opinion is that a quantity limit exception for Sildenafil 20 milligram tablets 180 per 30 days  is met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro ellipta 62.5/25 micrograms. The Part D plan denied the 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 prescriber was asked to send in medical records to support the diagnosis listed. We received a response and have included it in our review.The prescribers statement shows you were prescibed Anoro ellipta to treat your chronic obstructive pulmonary disease. However, the medical records from date of service 2/8/2021 do not support the diagnosis listed. Therefore, based upon the current record, it could not be determined whether the requested drug was being prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Actemra ACTPen 162milligrams/0.9milliliter injection prescribed as directed for VEXAS (Vacuoles, El ubiquitin activating enzyme, X-linked, auto inflammatory, somatic) 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Actemra ACTPen to treat your VEXAS syndrome. However, the Medicare approved compendia do not support the use of this drug for your conditions. 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 the Actemra ACTPen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide 0.5 milligrams per 2-milliliter ampule prescribed via nebulizer for chronic obstructive pulmonary disease. 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 doctor prescribed Budesonide for chronic obstructive pulmonary disease. However, this drug is eligible for coverage under Medicare Part B. Medicare Part B covers this drug for chronic obstructive pulmonary disease, when used with a nebulizer in the home (or in an assisted living facility). Medicare Part D cannot pay for drugs that are covered by Medicare Part B.We reviewed your appeal and determined that the plan is not required to cover Budesonide for nebulizer use.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Propafenone HCl 150 milligram tablet to treat the enrollees condition.   The Part D plan auto-forwarded your 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. A request was submitted to the prescriber to provide a diagnosis, to address the tiering exception criteria, and to provide supporting medical records.  A reply from the prescriber was not received. Propafenone HCl 150 milligram tablet is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective 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

At issue is Creon 12,000-38,000-60,000 units delayed-release oral capsule prescribed twice daily for recurrent pancreatitis. 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.Creon is a biological drug on Tier 3 of the plans formulary. There are no biological 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 the tiering exception. There are no lower tiered biological drugs of the same type to treat your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcipotriene 0.005% cream to treat actinic keratosis. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 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 this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 20 milligram tablets to treat benign prostatic hyperplasia with nocturia. 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.In this instance, the medical records submitted indicate a diagnosis of benign prostatic hyperplasia with nocturia. However, the records indicate Tadalafil 20 milligram tablets are prescribed for erectile dysfunction.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, 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 Rivastigmine 9.5 milligram/24 hour patch prescribed as directed for vascular demential without behavioral disturbance. 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 record shows you were prescribed the Rivastigmine patch to treat your condition. Since the drug isnt on the plans formulary it is not eligible for a tiering exception. 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 the Rivastigmine patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch for treatment of low back pain. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.The medical records show Lidocaine 5% patch was prescribed to treat low back pain. 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 Lidocaine patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Hizentra 10 gram per 50 milliliter solution. 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 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 prescriber has indicated that Hizentra has been prescribed for the following conditions: other specified polyneuropathies (G62.89); other disorders of autonomic nervous system (G90.8); disorder of the autonomic nervous system, unspecified (G90.9); and other specified diseases of the digestive system (K92.89). 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 noted conditions. Therefore, the requested drug is being prescribed for non-medically accepted indications and 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 Hizentra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Trulicity 0.75 milligram per 0.5 pen injector prescribed for type 1 diabetes. 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 Trulicity for type 1 diabetes.In review of the Medicare approved compendium, type 1 diabetes is not a medically accepted indication for Trulicity. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Trulicity at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Welchol 625 milligram tablets prescribed twice daily for functional diarrhea. 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 also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Welchol to treat your functional diarrhea. 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 the Welchol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone HCL ER 10 milligram tablets prescribed to treat the enrollees condition. The case was auto-fowarded by the plan. 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.Oxycodone HCL ER 10 milligram tablets is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain 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.A physician reviewed your appeal and  determined that the plan is not required to cover Oxycodone HCL ER 10 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Botox 200 unit vial prescribed for overactive bladder. 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 provided shows Boxtox was supplied by you and administered to the enrollee in your office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover Botox. Please submit your 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 Acthar gel 400 unit/5 milliliter vial prescribed for multiple sclerosis. 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. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Acthar gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nucynta 50 milligram tablets. 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. The submitted documentation does not include medical records to support a covered diagnosis. A request for a supporting statement and medical records was sent to your doctor. No further documentation was received. 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: Unfavorable

At issue is a request for Lidocaine 5 percent cream prescribed for chronic pain. 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 reviewed your appeal carefully. We reviewed all documentation available. Drugs prescribed that are available over the counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.We determined that the plan is not required to cover Lidocaine 5 percent cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Savella 100 milligram tablet prescribed for your severe depression. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Savella 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 coverage for non-formulary Colesevelam 625 milligram tablets. 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 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 indicates that Colesevelam has been prescribed for the treatment of chronic diarrhea due to non-infective gastroenteritis and colitis and a previous history of cholecystectomy and bowel resection. 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 noted 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 Colesevelam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sucralfate 1gm/10ml suspension to be given via gastrostomy tube. This drug is not on the plans formulary. At initial determination and redetermination the diagnosis of gastro-esophageal reflux disease without esophagitis was given. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication(s).  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.A request was submitted to the prescribing physician to clarify the diagnosis, address the formulary exception criteria, and to provide supporting medical records. At reconsideration a diagnosis of gastro-esophageal reflux disease without esophagitis , dysphagia - oropharyngeal phase, gastritis, and gastrointestinal hemorrhage was given. No medical records were provided by the prescriber to support this change of diagnosis. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested OyxContin 30 milligram tablets prescribed as directed for hip and pelvic pain related to 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 available documentation shows the enrollee was prescribed OxyContin for hip and pelvic pain related to lymphoma. The physician states the enrollee was prescribed OxyContin because Oxycodone was not available. However, the Food and Drug Administration Drug Shortages website does not provide evidence of a drug shortage of Oxycodone. Therefore, the available documentation does not support a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover the OxyContin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 10 milligram tablets. 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 submitted to the Part D plan indicates that Cyclobenzaprine Hydrochloride has been prescribed for chronic low back pain. 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 noted condition.It has been noted on the reconsideration request form that the Cyclobenzaprine Hydrochloride has been prescribed for acute skeletal muscle spasms. However, the submitted medical records do not indicate that the enrollee has acute skeletal muscle spasms. During this review, a prescriber statement and additional medical records were requested from the prescribing physician to validate and clarify what the Cyclobenzaprine Hydrochloride was being prescribed for, as the submitted documentation contained conflicting information. However, the prescribing physician did not respond to the request.Therefore, it is not possible to determine if the medication is being prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.