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

You requested a tiering exception for Eliquis 5 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 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 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 your appeal and determined that the plan is not required to cover the Eliquis at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20 milligram tablet three times daily to treat pulmonary artery hypertension related to scleroderma. 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 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.The documentation does not satisfy the plans coverage criteria. 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: Favorable

At issue is Tacrolimus 1 milligram capsules prescribed twice daily following a kidney 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. We also researched Medicare systems and reviewed the enrollment data available. Your records show your doctor prescribed Tacrolimus to prevent rejection following a kidney transplant. The Medicare approved compendia support the use of this drug for your condition. Based on the information provided, the drug is not eligible for Part B coverage. Therefore, the drug is eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is required to cover Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablets prescribe to treat inappropriate sinus tachycardia. 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. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia does not support the use of the drug for your conditionA physician reviewed your appeal and determined that the plan is not required to cover Corlanor.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Clobazam 10 milligram tablet, 15 milligrams in morning and 20 milligrams in evening, to treat Dravet syndrome and epilepsy. The Part D plan denied the request because it does not meet the planscriteria. 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.At reconsideration the diagnosis given is Dravet syndrome and epilepsy.  A citation in Micromedex, a Medicare approved compendium, supports the use of the requested drug for the condition indicated:  Clobazam is adjunctive treatment of refractory focal seizures (partial seizure and localization-related seizure) in children, young adults, and adults if first-line treatment is ineffective or not tolerated. Clobazam is adjunctive treatment of generalized tonic-clonic seizures in children, young adults, and adults if first-line treatment is ineffective or not tolerated. Additionally, this compendia reference includes a hyperlink to Practice Guidelines from the National Institute for Health and Care Excellence for the diagnosis and management of epilepsy in children, young adults, and adults. It specifically mentions Dravet Syndrome and use of Clobazam. Therefore, it is considered a medically accepted indication.The documentation does not satisfy the plans coverage criteria. The plans coverage criteria state that you need to have an FDA approved indication.  Therefore, an exception to the plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage..
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tobramycin 300 milligram/5 milliliter nebulized solution prescribed twice daily for treatment of lung infection with mycobacterium chelonae-abscessus group. The Part D plan denied your request because the requested 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. Your medical records show your doctor prescribed Tobramycin to treat a bronchopulmonary infection caused by mycobacterium chelonae-abscessus group. However, the Medicare approved compendia do not support the use of this drug for your condition. As such, 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 Tobramycin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for right femur and hip fracture. 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 indicates your doctor prescribed Lidocaine patch for right femur and hip fracture. 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 Xifaxan 550 milligrams prescribed as directed for elevated ammonia level and liver failure. 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 prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the plans prior authorization criteria. We received the documentation and included it in our review.The prescribers statement show your doctor prescribed Xifaxan to treat your condition. However, no medical records were submitted to support the diagnosis. Therefore, based upon the current record, 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 the Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide EC 3 milligram capsules prescribed three times daily for graft versus host disease. 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 Budesonide EC 3 for graft versus host disease. However, 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 Ilumya 100 milligram/milliliter injection prescribed for plaque psoriasis. 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. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Ilumya.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Metanx 3 milligram capsules prescribed daily for neuropathic pain. 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.We determined that the plan is not required to cover Metanx because it was a prescription vitamin 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 microgram/actuation disk prescribed as directed for chronic obstructive pulmonary disease. 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 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 the Anoro ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nulojix 250 milligram vial prescribed daily for 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 plan is not required to cover the Nulojix. Medicare records indicate the enrollee received a kidney transplant on September 10, 2014, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Nulojix 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 Gammunex-C 5 gram/50 milliliter intravenous solution prescribed as directed for myasthenia gravis. 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 medical records show you were prescribed Gammunex-C to treat your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has been met. 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 Gammunex-C.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 3% gel to treat the enrollees cervicalgia, sciatica, and calf muscle spasm. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dextroamphetamine-Amphetamine 10 milligram capsules prescribed daily for multiple sclerosis. 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 Dextroamphetamine-Amphetamine for multiple sclerosis. 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

You requested a tiering exception for Breo Ellipta 100 microgram-25 microgram inhalation powder. 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. Breo Ellipta 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. 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 your appeal and determined that the plan is not required to cover the Breo Ellipta at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Latuda 40 milligram tablets. The Part D plan denied the 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 on Tier 5 which is the plans Specialty Tier. Specialty Tier drugs are not available for a tiering exception per Medicare rules.  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 Faserna 30 milligram injection prescribed as directed for moderate persistent asthma. 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 medical records show your doctor prescribed Faserna to treat your condition. 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 Faserna.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xelianz 5 milligram tablet to treat rheumatoid arthritis. 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 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.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stelara 45 milligrams per 0.5 milliliter syringe to treat psoriasis. 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 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. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

You requested Jakafi 5 milligram tablets prescribed for chronic neutrophil leukemia with colony-stimulating factor 3 receptor mutation. 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 for information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested.The medical records show you prescribed Jakafi to treat the enrollees chronic neutrophil leukemia with colony-stimulating factor 3 receptor mutation. The medical records submitted indicate that the enrollees disease is uncontrolled on Hydrea and Dasatnib. Per the National Comprehensive Cancer Network, there is no standard of care for chronic neutrophil leukemia with colony-stimulating factor 3 receptor mutation. The provider has submitted a Phase 2 study of Ruxolitinib in patients with chronic neutrophil leukemia published by Blood, a Medicare approved journal. The study showed that Jakafi had clinical benefit in participants with colony-stimulating factor 3 receptor mutation. Therefore, an exception to the plan's coverage criteria can be made.A physician reviewed your appeal and determined that the plan is required to cover Jakafi 5 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Colcrys 0.6-milligram tablets prescribed for pseudogout. 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 Colcrys for pseudogout. In review of the Medicare approved compendium, pseudogout is not a medically accepted indication for Colcrys. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Colcrys at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Budesonide EC 3 milligram capsules prescribed for refractory celiac disease and pancreatic insufficiency. 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 Budesonide EC for refractory celiac disease and pancreatic insufficiency. In review of the Medicare approved compendium, celiac disease and pancreatic insufficiency are not medically accepted indications for Budesonide EC. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Budesonide EC at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 20 microgram injection prescribed for treatment of osteoporosis in a post-menopausal patient. The Part D plan denied coverage.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 plan has prior authorization criteria assigned to the drug at issue. The enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Remicade 100 milligram solution prescribed for rheumatoid arthritis. 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. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Remicade.