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

At issue is Xifaxan 550 milligram tablets prescribed daily for hepatic encephalopathy. 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 Xifaxan 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 coverage for Berinert 500 units injection kit prescribed for hereditary angioedema. We received an auto-forwarded reconsideration request from the coverage level.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 Part D plan has prior authorization requirements that must be met before Berinert will be covered. During this review, a prescriber statement and additional medical records and laboratory results were requested from the prescribing physician to address the plans specific coverage criteria. While the prescribing physician responded and answered questions regarding the prior authorization requirements, the prescribing physician did not submit laboratory results, specifically C1 esterase inhibitor levels to validate the answers, as requested. Therefore, it is not possible to confirm that the plans prior authorization requirements have been satisfied for the medication. A physician reviewed your appeal and determined that the plan is not required to cover the Berinert.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tobramycin 300 milligram/5 milliliter ampule prescribed daily for cerebral palsy. 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 Tobramycin is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Tobramycin. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Praluent 75 milligram/milliliter injector 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.Praluent is a brand biologic on Tier 3 of the plans formulary. There are no brand biologics of the same type on the lower cost sharing tiers. Therefore, this biologic 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 Gammaplex 10 percent 20 grams/200 milliliters prescribed for neuromyelitis optica spectrum 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 Gammaplex for neuromyelitis optica spectrum disorder.In review of the Medicare approved compendia, neuromyelitis optica spectrum disorder is not a medically accepted indication for Gammaplex. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Gammaplex at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Abelcet 100 milligram/20 milliliter vial via nebulizer for infection prophylaxis following a lung transplant. 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 Abelcet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate 250 milligram oral capsule prescribed daily for immunosuppression management following a kidney transplant. The Part D plan denied the request because drugs that could be covered under Medicare Part A and/or Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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 Mycophenolate was prescribed to treat transplant immunosuppression. The enrollee received a kidney transplant October 14, 2020, due to end-stage kidney disease secondary to hypertensive nephrosclerosis. The enrollee did not have Medicare coverage at this time. The records do not show that Medicare covered the transplant. Therefore, this drug is not eligible for coverage under Medicare Part D. We determined that the plan is not required to cover Mycophenolate under the Medicare Part D Prescription Drug benefit.
Appeal type: Prescription Drug
Decision: Favorable

You requested Mycophenolate Mofetil 250 milligram capsules prescribed as directed following a kidney transplant. 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 determined that the drug is not eligible for Part B coverage. Medicare enrollment records show the enrollee was entitled to Medicare Part A coverage on March 1, 2021. The documentation submitted states the enrollee received a kidney transplant on October 14, 2020. The enrollee was not eligible for Medicare at the time of the transplant. Therefore, the drug can be considered for payment under the Part D benefit. The medical records show the doctor prescribed Mycophenolate Mofetil to provide immunosuppression following a kidney transplant. The documentation shows the enrollee is also prescribed Tacrolimus. The Medicare approved compendia do support the use of this drug, in combination with other immunosuppressants, to prevent kidney transplant rejection.A physician reviewed your appeal and determined that the plan is required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydroxyzine Hydrochloride 25 milligram tablets prescribed for insomnia. 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 indicates your doctor prescribed Hydroxyzine Hydrochloride for 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: Unfavorable

At issue is Fentanyl 75 micrograms per hour patch prescribed for the enrollees condition. 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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.A diagnosis was not submitted. No medical records were provided by the prescriber to support a diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover the Fentanyl patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Morphine Sulfate ER 60 milligram tablets prescribed every eight hours, as needed for low back pain, neck pain, and compression fracture of the second lumbar vertebra. 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. We also asked for medical records or other documentation to show why you need this amount of the medication. A reply from the prescriber was not.Your doctor prescribed Morphine Sulfate ER tablets to treat your condition. However, your medical records do not support why an exception to the plans quantity limit is medically necessary.A physician reviewed your appeal and determined that the plan is not required to cover the Morphine Sulfate ER tablets as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tobramycin 300 milligram/4 milliliter nebulizer solution prescribed for severe cystic bilateral bronchiectasis. 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 for use with 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 Tobramycin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac gel 1 percent, 100 grams/25 days. At initial determination and redetermination the diagnosis of rheumatoid arthritis 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. At reconsideration a diagnosis of osteoarthritis was given. Medical records were provided by the prescriber to support this diagnosis, including exam finding of Heberdens nodules  osteoarthritis of the hands. The requested drug was being prescribed for a medically accepted indication. The documentation though does not satisfy the plans coverage criteria that are approved by Medicare. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 2.5 milligram/3 milliliter vial prescribed every 8 hours per 9 days for unknown diagnosis. 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 Albuterol sulfate is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Albuterol sulfate. 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

You requested Lupron Depot 45 milligrams intramuscular injection prescribed every six months for prostate cancer. 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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records to show why the enrollee needs this medication. We did not receive the documentation requested.The documentation shows the physician prescribed Lupron Depot to treat prostate cancer. No medical records were provided by the prescriber to support the enrollees diagnosis and stage of disease. 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 Lupron Depot.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methscopolamine Bromide 5 milligram oral tablet prescribed daily for gastroesophageal reflux disease without esophagitis. 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 your doctor prescribed Methscopolamine Bromide to treat your gastroesophageal reflux disease without esophagitis and gastritis. However, the Medicare approved compendia do not support the use of this drug for your condition. As such, an exceptions request based on non-formulary 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.A physician reviewed your appeal and determined that the plan is not required to cover Methscopolamine Bromide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mavyret 100-40 milligram tablets prescribed for Hepatitis C with compensated cirrhosis, treatment-naive. 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. The records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. The prescriber statement does not provide patient specific clinical rationale, with supporting medical documentation, to indicate that all alternatives required by the plan have been tried and failed, or why the alternative drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Modafinil 200 milligrams prescribed daily for fatigue and drowsiness due to sleep apnea. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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 Modafinil for fatigue and drowsiness due to sleep apnea. The Medicare approved compendia do support the use of this drug for your condition. The plan requires a diagnosis of obstructive sleep apnea confirmed by polysomnography. 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 Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omnipod Dash 5 pack pod prescribed for diabetes mellitus. 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. The medical records show the physician prescribed Omnipod Dash to treat your diabetes mellitus. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entocort EC 3 milligram capsule prescribed for ulcerative colitis. 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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.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. A physician reviewed your appeal and determined that the plan is not required to cover Entocort EC.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Sumatriptan Succinate 100 milligram tablets, 60 tablets for 30 days, purchased on March 13, 2021, for S27.23.We received a case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. The record shows that a GoodRx coupon was applied to the purchase of the medication. When you used the GoodRx coupon, you acknowledged and agreed that GoodRx will be treated as the primary payer with respect to the medications that you have selected to purchase through the GoodRx discount program. Therefore, the plan is not required to cover or provide reimbursement for the remaining cost of the Sumatriptan Succinate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Phenazopyridine Hydrochloride 100 milligram tablets prescribed for acute cystitis without hematuria. 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 reviewed your appeal carefully. We reviewed all documentation available.We determined that the plan is not required to cover Phenazopyridine Hydrochloride because the drug has not been approved by the Food and Drug Administration for the treatment of any condition. Drugs that have not been approved by the Food and Drug Administration 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

At issue is Benzonatate 200 milligram capsule prescribed for chronic 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 Lupron prescribe to treat metastatic prostate cancer. We received the case to perform an independent and de novo review. To make our decision, we read all documentation submitted. This includes any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. We requested additional documentation from the prescriber including the medical records supporting the diagnosis, the frequency and dosage of the drug in question, and what other drugs have been tried for your condition. We did not receive a response. The documentation is insufficient to determine if the drug is medically indicated for your condition, covered under Part D drug benefits, and medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover Lupron.