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

At issue is Armodafinil 200 milligram tablets prescribed for idiopathic hypersomnia. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered Armodafinil for idiopathic hypersomnia. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zarxio 300 microgram/0.5 milliliter prescribed for neutropenia, unspecified with history of lung transplant and profound weakness due to critical illness polyneuropathy/myopathy. 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 Zarxio was prescribed to treat neutropenia, unspecified with history of lung transplant and profound weakness due to critical illness polyneuropathy/myopathy. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Zarxio.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Siliq 210-milligram/1.5-milliliter Solution Prefilled Syringe to treat hidradenitis suppurativa. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The 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 Otezla 28-Day Starter Pack to treat cicatricial pemphigoid. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The 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 Panzyga 10-grams/100-milliliters Solution to treat chronic autoimmune encephalitis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The 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

You requested Cyclobenzaprine 15 milligram tablets prescribed as directed for skeletal muscle spasm, associated with chronic, painful musculoskeletal conditions. 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 Cyclobenzaprine to treat your skeletal muscle spasm, associated with chronic, painful musculoskeletal conditions. However, the Medicare approved compendia do not support the use of this drug for your chronic condition. A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidoderm 5 percent patch prescribed as directed for low back pain. 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Lidoderm 5 percent patch.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Hycoscyamine Sulfate 0.125 tablet prescribed for unspecified abdominal pain. The Part D plan denied the enrollees 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 Hycoscyamine Sulfate is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover Hycoscyamine Sulfate. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ocrevus 300 milligram/10 milliliter injection prescribed as directed for multiple sclerosis. 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Ocrevus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Ondansetron Hydrochloride 4 milligram tablets. The Part D plan denied the request for coverage. 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 submitted to the plan indicates that Ondansetron Hydrochloride has been prescribed for the treatment of nausea associated with migraines. At reconsideration, the enrollee has noted that Ondansetron Hydrochloride is being used for frequent nausea that is not related to any specific condition. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of either noted condition. Therefore, the drug is being prescribed for non-medically accepted indication(s) and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Shingrix 50 microgram per 0.5 milliliter suspension injection (vaccination) prescribed for shingles prevention. The Part D plan denied the request because there was no proof of payment from the doctors office.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 states that the enrollee received Shingrix 50 microgram per 0.5 milliliter suspension injection (vaccination) on March 29, 2021, while at the doctors office. The enrollees Part D plan requires proof of payment from the doctors office. There is no documentation indicating the enrollee paid for the requested drug. The enrollee did not provide proof of payment.We determined that the plan is not required to cover the Shingrix 50 microgram per 0.5 milliliter suspension injection (vaccination) because the enrollee has not submitted the proof of payment from the doctors office.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Megestrol Acetate 400-milligrams/10-milliliters. At initial determination and redetermination the diagnosis of loss of appetite and non-infective gastroenteritis and colitis, unspecified was given.. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.At reconsideration a diagnosis of personal history of other malignant neoplasm of large intestine was given. Medical records were provided which documented a history of removal of a villous adenoma in 2019. The use of the requested drug to treat the provided diagnoses are off-label uses. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. 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 a request for coverage of Nulojix 250 milligram solution prescribed for rejection of a transplanted kidney. The Part D plan denied your requestWe received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the enrollee had a kidney transplant on August 5, 2020. According to Medicare enrollment records, the enrollee was entitled to Medicare Part A coverage at the time of the transplant. Therefore, the transplant is considered a Medicare covered transplant and Nulojix is eligible for coverage under Medicare Part B. Medicare Part B covers prescription drugs used in immunosuppressive therapy furnished to an enrollee who has received an organ transplant. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. We determined that the Medicare Part D plan is not required to cover Nulojix. This decision does not concern 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 Pregabalin 50 milligram capsules. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records to support a covered diagnosis and a prescriber statement. However, we did not receive the requested information.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Tadalafil 5 milligram tablets prescribed for benign prostatic hyperplasia. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to indicate all formulary alternatives were tried and failed. We received the requested information and included it in this review.The plan initially denied payment for Tadalafil as the prescriber ordered a dosage that was not medically indicated for the enrollees condition. Upon appeal, the prescriber indicated the prescribed dose for Tadalafil is 5 milligram tablets per day and not 10 milligrams per day. The Medicare approved compendia support the dosage of 5 milligram tablets per day for the enrollees condition. However, the supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lumakras 120-milligram tablet to treat recurrent adenocarcinoma of the lung, with brain metastases with the presence of KRAS G12C mutation, without prior systemic therapy. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The 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. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal.  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 a request for coverage of Stelara 45 milligram per 0.5 milliliter prefilled subcutaneous injection syringe. The Part D plan denied the request for coverage. 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 Stelara has been prescribed for the treatment of rheumatoid arthritis and HLA-27 ankylosing spondylitis. 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 drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin 40-milligram Tablet Extended Release 24-Hour Abuse Deterrent to treat chronic pain. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to 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 formulary coverage criteria is not supported. 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 Nucynta ER 50 milligram tablets prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Tacrolimus 1 milligram capsule prescribed daily to prevent kidney transplant rejection. The Part D plan denied the enrollees 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 Part D plan is not required to cover the Tacrolimus. Medicare records indicate the enrollee received a kidney transplant on October 22, 2016, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Tacrolimus is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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 Uribel capsule prescribed for interstitial cystitis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Non-FDA approved drugs are excluded from Medicare Part D coverage.  Therefore, Uribel is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablets prescribed for chronic atrial fibrillation. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level. The drug will continue to be covered at the Tier 3 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metaxalone 400-miligram tablet to treat pain due to intervertebral disc degeneration, lumbar region.  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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omega 3-Acid Ethyl Esters prescribed for marked hypertriglyceridemia. 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 the 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 prescriber indicates the enrollee has an intolerance (myalgia) to multiple statins and is on fibrate therapy with most recent triglyceride level still at 394. However, the Medicare approved compendia do not support the use of this drug for this condition without a triglyceride level of 500 milligram/deciliter or higher.  A physician reviewed your appeal and determined that the plan is not required to cover Omega 3-Acid Ethyl Esters.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Glassia 1 gram per 50 milliliter vial for intravenous infusion prescribed for the treatment of alpha-1-antitrypsin deficiency. The Part D plan denied the request for coverage.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. Glassia is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient patient specific clinical rationale as to why the formulary alternatives included in the plan to treat the enrollees condition, would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.