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

You requested Lenvima 10 milligram capsules prescribed as directed for metastatic uterine cancer. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the physician prescribed Lenvima to treat metastatic uterine cancer. The enrollee was initially diagnosed with uterine cancer in 2011. Since that time, the enrollee has had metastatic disease despite multiple lines of treatment. Most recently, the enrollee was treated with Taxol. The enrollee has metastatic lung disease along with abdominal disease, and is not a candidate for surgery or radiation. The documentation shows the enrollee underwent testing for microsatellite instability. The enrollee has experienced disease progression while being treated with Taxol. Therefore, the physician has prescribed Lenvima to be given with Keytruda for an enrollee that is microsatellite stable. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for the enrollees condition: Lenvatinib, in combination with Pembrolizumab, is indicated for the treatment of patients with advanced endometrial carcinoma that is not microsatellite instability-high or mismatch repair deficient, who have disease progression following prior systemic therapy and are not candidates for curative surgery or radiation. The documentation shows the enrollee is using the requested drug for a Food and Drug Administration-approved indication and has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Lenvima.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed as directed for unspecified chronic pain syndrome. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Cyclobenzaprine Hydrochloride to treat chronic low back pain.  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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Fluocinonide 0.05% gel prescribed for lichen planus, unspecified. 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 Fluocinonide to treat your lichen planus, unspecified. 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 Fluocinonide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Glycopyrrolate 1 milligram oral tablets prescribed as directed for primary focal hyperhidrosis. 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 the doctor prescribed Glycopyrrolate to treat primary focal hyperhidrosis. 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 Glycopyrrolate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Octreotide Acetate 50 microgram/1 milliliter injection solution prescribed for gastrointestinal bleeding. 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 Octreotide Acetate for gastrointestinal bleeding associated with arteriovenous malformations. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As the drug was not 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 Levemir FlexTouch 100 units per milliliter solution pen-injector prescribed to inject 30 units subcutaneously once daily to treat diabetes. 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 Levemir FlexTouch 100 units per milliliter solution pen-injector.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mektovi 15 milligram tablet prescribed for metastatic non-small-cell lung carcinoma. 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 records show you prescribed Mektovi 15 milligram tablet to treat the enrollees metastatic non-small-cell lung carcinoma. However, the Medicare approved compendia and Medicare approved journals do not support the use of this drug for this condition. An oncologist reviewed your appeal and determined that the plan is not required to cover Mektovi 15 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 200-62.5-25 inhaler 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. 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 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 the off formulary drug Ubrelvy 50 milligram tablet prescribed for chronic cluster headaches. 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 Ubrelvy to treat your cluster headaches. 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 Ubrelvy.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gamunex-C 10 gram/100 milliliter prescribed 300 milliliters every 28 days for primary immune deficiency. 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 requested drug is administered in the home for primary immune deficiency. However, this drug may be eligible for coverage under Medicare Part B. We determined that the plan is not required to cover Gamunex-C. Drugs administered in the home for treatment of immune deficiency disease is covered by Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablet prescribed for hepatic encephalopathy. 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. This specialty drug was approved as a recurring 30-day supply. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover the requested 90-day supply. A physician reviewed your appeal and determined that the plan is not required to cover a 90-day supply of Xifaxan 550 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Relistor 150 milligram tablet prescribed to take 450 milligrams, daily for opioid-induced constipation. 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 Relistor tablet(s) to treat your opioid-induced constipation related to chronic use of opioids for metastatic prostate cancer. The medical record supports that patient has advanced cancer pain; use of opioids is with palliative intent. However, the Medicare approved compendia do not support the use of this drug in tablet form for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Relistor tablet(s).
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram/milliliter autoinjector prescribed for hyperlipidemia. 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 Repatha Sureclick 140 milligram/milliliter autoinjector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mayzent 2 milligram tablet to treat multiple sclerosis. 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.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 Armour Thyroid 120 milligram oral tablet. 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. Armour Thyroid is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 30 milligram oral tablet. 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. Armour Thyroid is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Femara 2.5 milligram tablet prescribed for breast cancer. 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 Femara 2.5 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligrams/2 milliliters. At initial determination and redetermination the diagnosis of prurigo nodularis was given. 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.At reconsideration a diagnosis of atopic dermatitis was given. The medical records support this diagnosis. However, 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

At issue is Tretinoin 5% Cream to treat discoid lupus erythematosus and acne. 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 documentation satisfies the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Toprol XL 25mg tablet to treat hypertension. 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.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 Tadalafil 5 milligram tablets prescribed daily 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.Tadalafil is a non-formulary brand drug. 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

At issue is Iclusig 15 milligram tablet prescribed for Philadelphia positive acute lymphoblastic leukemia. 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. The medical records show you prescribed Iclusig 15 milligram tablet to treat the enrollees Philadelphia positive acute lymphoblastic leukemia. The 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.An oncologist reviewed your appeal and determined that the plan is not required to cover Iclusig 15 milligram tablet. 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

At issue is a request for coverage of Tadalafil 5 milligram tablets. The Part D plan denied the request stating that drugs prescribed for the treatment of erectile dysfunction are excluded from Part D 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. The documentation indicates that Tadalafil 5 milligram tablet is being prescribed for the treatment of benign prostatic hyperplasia. The Medicare approved compendia support the use of the requested drug, as prescribed, for the treatment of this condition. However, Tadalafil 5 milligram tablet is not included in the plans formulary. During this review, a request was submitted the prescriber to address the formulary alternatives to treat the enrollees condition. The prescriber responded to the request; however, the prescriber did not address each formulary alternative and provide patient specific clinical rationale as to why these drugs 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 Tymlos Solution Pen-Injector 3120-micrograms/1.56-milliliters to treat age-related osteoporosis without current pathological fracture. 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 documentation provided addressed the plans coverage criteria, and those criteria were not satisfied. The beneficiary has had 24 months lifetime total for parathyroid hormone analogs.  The prescriber stated that the enrollee has failed Forteo from 2004-2006.  DrugDex, a Medicare approved compendium states for Tymlos, 'Limitations of Use:  Do not use for more than 2 cumulative years during a patient's lifetime, including other parathyroid hormone analogs; osteosarcoma has occurred in rodents with unknown relevance to humans [1].  1. Product Information: TYMLOS(TM) subcutaneous injection, abaloparatide subcutaneous injection. Radius Health, Inc (per FDA), Waltham, MA, 2017.'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 Budesonide 0.5 milligram per 2 milliliter ampules prescribed for the treatment of COVID-related pneumonia with underlying chronic obstructive pulmonary disease. 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 indicates that the Budesonide is going to be administered via nebulizer. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment, such as a nebulizers. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Coverage under Part D is excluded for any drug for which payment would be available under Part B. We determined that the Medicare Part D plan is not required to cover the Budesonide. 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. Please submit your request to Medicare Part B.