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

At issue is Galzin (zinc acetate) to treat Wilsons disease.   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.Drugs prescribed for use as vitamins and minerals 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 milligrams per 24 hour patch prescribed daily for Parkinsons disease and dementia. 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 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. Rivastigmine 9.5 milligrams per 24 hour patch is a generic drug on Tier 4 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine Hydrochloride 25 milligram tablet prescribed for intermittent nausea of unknown origin. 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. 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, as ordered, is not being used for a medically accepted indication. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules. 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 Promethazine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Latuda 20 milligram tablets. The Part D plan denied the request at redetermination because the plans prior authorization requirements were not met.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 submitted a list of diagnoses at redetermination that indicates bipolar disorder (added on August 3, 2021). However, the submitted progress notes indicate that Latuda has been prescribed for the treatment of major depressive disorder. There is no indication anywhere in the progress notes that the enrollee was being treated for bipolar disorder or that Latuda was being prescribed for bipolar disorder. The Medicare approved compendia do not contain any citations to support the use of the use of Latuda, as prescribed, for the treatment of major depressive disorder. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage, the plans prior authorization requirements are not relevant to this review. 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 Otezla 30 milligram tablet prescribed for plaque psoriasis. 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 records submitted at the reconsideration level. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug.A physician reviewed your appeal and determined that the plan is not required to cover Otezla. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Kineret 100 milligram/0.67 milliliter solution prefilled syringe prescribed as directed for hidradenitis suppurativa. 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 Kineret to treat your hidradenitis suppurativa. 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 your appeal and determined that the plan is not required to cover Kineret.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Januvia 100 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. Januvia 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 the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec 75 milligram orally dissolving tablet prescribed every other day for migraines. 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. 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 the appeal and determined that the plan is not required to cover Nurtec 75 milligram orally dissolving tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Nexletol 180 milligram prescribed for hyperlipidemia. 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. The documentation shows Nexletol was prescribed to treat mixed hyperlipidemia. 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 Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Deferasirox 250-milligram Tablet Dispersible to treat iron overload syndrome. 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 hemochromatosis was added. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.It is noted that the physician changed the dosage of Deferasirox 250-milligram Tablet Dispersible to 360-milligram Tablet Dispersible. The dosage cannot be changed at reconsideration. The physician will need to submit another request to the plan for the changed dosage.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Eliquis 5 milligram prescribed for an unknown diagnosis. 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 the plan reprocessed the enrollees claim for the Eliquis and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because Medicare records indicate the enrollee did not qualify for low income subsidy copay level. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the remaining copay. We have determined that the plan is correct in its recalculation of the enrollees copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 3 percent gel prescribed as directed for primary osteoarthritis, right ankle and foot. 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 Diclofenac Sodium 3% gel to treat your primary osteoarthritis, right ankle and foot. 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 Diclofenac Sodium 3% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xiidra 5% Eye Drops to treat dry eye syndrome of bilateral lacrimal glands and sicca syndrome with keratoconjunctivitis. 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 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 Albuterol Sulfate 2.5 milligram/3 milliliter vial prescribed for 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 documentation 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: Favorable

At issue is Cinacalcet Hydrochloride 30 milligram tablet prescribed two tablets twice daily for hypercalcemia in a renal transplant recipient with persistent hyperparathyroidism. 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.We determined that the drug is not eligible for Part B coverage. The enrollee is not an End-Stage Renal Disease patient currently receiving dialysis treatment. Therefore, the drug can be considered for payment under the Part D benefit.The doctor prescribed Cinacalcet Hydrochloride to treat the enrollees hypercalcemia in a renal transplant recipient with persistent hyperparathyroidism. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for the enrollees condition: Cinacalcet treatment significantly decreased the mean corrected total serum calcium to less than 10.2 milligrams per deciliter in 78.9% of patients compared with 3.5% with placebo in a 26-week, randomized study of renal transplant recipients with hypercalcemia and persistent hyperparathyroidism.The documentation satisfies the plans coverage criteria.  A physician reviewed the appeal and determined that the plan is required to cover Cinacalcet Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Hydrochloride Urethral/Mucosal Gel 2% prescribed for skin irritation. 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 requested additional information from the prescriber to confirm a diagnosis but did not get a response. In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, documentation supporting a medically accepted indication is required. Medicare approved compendia do not support the use of this drug for the reported condition.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine Hydrochloride Urethral/Mucosal Gel 2%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100-62.5 micrograms blister with inhalation device. The Part D plan denied the appeal request for a tiering exception.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.Trelegy 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. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tirosint 50 microgram tablets prescribed as directed for hypothyroidism. 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 Tirosint.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Udenyca solution 6 milligram/0.6 milliliter prefilled syringe prescribed for malignant neoplasm of bladder. 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 asked the prescriber to send us information regarding the enrollee's condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. 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 records provided do not support a medically accepted indication, and why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to Udenyca.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fosfomycin 3 gram sachet prescribed as directed for urinary tract infection in a male enrollee. The Part D plan denied 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.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 Methocarbamol 500 milligram tablet prescribed for restless leg syndrome. 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. The prescriber indicates that Methocarbamol is prescribed as needed for primary osteoarthritis, chronic low back pain, and restless leg syndrome. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed your appeal and determined that the plan is not required to cover Methocarbamol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Enbrel SureClick 50 milligram/milliliter prescribed for psoriatic 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. We asked the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. We received the documentation and included it in our review.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 all drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to Enbrel SureClick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablet. 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 requested additional information from the prescriber but did not get a response. In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, documentation supporting a medically accepted indication is required. This information was requested from the prescriber and we did not receive information that could answer these medical necessity issues.  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 Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Mycophenolic Acid 180 milligram DR tablet prescribed to prevent kidney transplant rejection. 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.The record shows the enrollee had a kidney transplant on March 22, 2021. 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 Mycophenolic Acid 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 Mycophenolic Acid. 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.