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

You requested coverage for Colistimethate Sodium 150 milligram solution for inhalation via nebulizer, which has been prescribed for cystic fibrosis and pseudomonas infection. 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 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: Unfavorable

You requested a lower cost tiering exception for Dilantin 100 milligram capsules prescribed for epilepsy with history of seizures. 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. Dilantin is a brand drug on Tier 4 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 Dilantin at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dalfampridine ER 10 milligram tablet prescribed to treat multiple sclerosis. 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 levelThe medical records show you were prescribed Dalfampridine ER 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 Dalfampridine ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Carafate Suspension 1 gram/10 milliliter prescribed as directed for gastroesophageal reflux disease without esophagitis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Carafate Suspension to treat your gastroesophageal reflux disease without esophagitis. 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 the enrollees condition. 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 the Carafate Suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Methadone 5 milligram tablets prescribed for pain management due to multiple chronic conditions. 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed all of the prior authorization requirements for coverage of this medication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Votrient 200 milligram tablets prescribed as directed for metastatic Merkel cell 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 record shows the physician prescribed Votrient for metastatic Merkel cell carcinoma. The enrollee was previously treated with Avelumab. However, treatment with Avelumab was not tolerated because the enrollee has myasthenia gravis; the enrollee was also unable to receive additional immunotherapy. Second line treatment was given with Carboplatin and Etoposide for six cycles, but the enrollee experienced disease progression. The enrollee is not a good candidate for further chemotherapy due to the development of cytopenias, which chemotherapy can exacerbate.Metastatic Merkel cell carcinoma is a rare malignancy with no prospective studies and most data from retrospective analyses at single institutions. According to the National Comprehensive Cancer Network guidelines, clinical trial is the preferred treatment option. However, if that is not possible then immunotherapy and chemotherapy is recommended. The documentation submitted shows the enrollee has exhausted all National Comprehensive Cancer Network recommended treatments. The provider also submitted an article from the Journal of Clinical Oncology showing a case report where a patient who had been on similar treatment to this patient responded to Votrient. In addition, the Journal of Clinical Oncology indicates there is a phase 2 trial showing benefit with Votrient for patients with metastatic Merkel cell carcinoma. Therefore, the Medicare approved compendium does support the use of this drug for the treatment of the enrollees condition. Furthermore, an exception to the plans prior authorization criteria is medically necessary for this enrollee. A physician reviewed your appeal and determined that the plan is required to cover the Votrient.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mycophenolate Mofetil 500 milligram tablets 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.The records show you received a kidney transplant on November 11, 2020. Based on the information provided, we determined the drug could be eligible for coverage under Part D. There is no information in the Medicare Database that indicates you had a covered transplant, paid for by Medicare or were enrolled in Medicare Part A at the time of the transplant. This drug is on the plans formulary and is being used for a medically accepted indication.A physician reviewed your appeal and determined that the requested drug should be covered by your Part D plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Xeljanz 5 milligram tablets. 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 information submitted at the reconsideration level.The documentation indicates that Xeljanz has been prescribed for the treatment of dermatomyositis. 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 condition. Therefore, the drug is being prescribed for a non-medically accepted indication and 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 Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Revlimid 10 milligram capsule to treat pemphigus erythematosus, discoid and systemic lupus erythematosus. 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 Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition(s). There was no peer-reviewed, clinically relevant, medical literature from an approved journal(s) submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. As such, medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition(s).
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuedexta 20 milligram-10 milligram capsules prescribed for pseudobulbar affect. 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 documentation supports the drug was prescribed for the enrollees diagnosis of pseudobulbar affect. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.  Relevant medical records were requested and were not provided.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 a tiering exception request for Carbamazepine ER 200 mg tablets to treat the enrollees condition.   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.Carbamazepine ER 200 mg tablets is a generic drug on Tier 4 of the plans formulary.  The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lyrica 200 milligram capsules prescribed to treat an enrollee with diabetes, headache, tremors, and disorder of the autonomic nervous system. 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. 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 Lyrica.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine-Dextroamphetamine 20 milligram tablets prescribed for major depressive disorder and 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. The submitted documentation indicates your doctor prescribed Amphetamine-Dextroamphetamine for major depressive disorder and 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

At issue is Enbrel Sureclick 50 milligram/milliliter subcutaneous injection prescribed for the enrollees condition. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.This drug is being provided by the plan at the cost sharing level of the 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 Azathioprine 50 milligram tablet to treat relapsing polychondritis. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received an expedited 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 does 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 Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Viibryd 40 milligram tablets prescribed daily for major depressive disorder, moderate to severe. 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. Viibryd 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. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Gilotrif 40 milligram tablet to treat metastatic squamous cell lung cancer. 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 physicians records show that the enrollee has metastatic poorly differentiated squamous cell cancer that progressed following previous platinum-based chemotherapy and radiation. The lung lesions are not known to be a new primary cancer. National Comprehensive Cancer Network (NCCN) guidelines include recommendations for Gilotrif as a single agent, subsequent-line option for non-nasopharyngeal cancer if disease progresses after platinum therapy in patients with performance status 0-2 with recurrent/persistent disease with distant metastases, which is this enrollee's condition. Medicare approved compendia support the use of this drug in this condition. 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 Cinacalcet HCl 30 milligram tablets prescribed for secondary hyperparathyroidism. 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 Cinacalcet HCl for secondary hyperparathyroidism in an enrollee not on dialysis. The medical records submitted indicate your doctor believes your diagnosis should be primary hyperparathyroidism; however, the Medicare approved compendia do not support the use of this drug for your condition. The submitted records do not support 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: Favorable

You requested Alecensa 150 milligram capsule prescribed for non-small-cell lung cancer with anaplastic lymphoma kinase positive request. 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 enrollee was initially diagnosed in 2011 following surgery and chemo-radiation. In 2014, the enrollee developed metastatic disease in the brain. Subsequently, in 2020, the enrollee had radiation to the left chest wall due to metastatic disease with a biopsy revealing anaplastic lymphoma kinase positive request. The Medicare approved compendia support the use of this drug for this condition. An oncologist reviewed your appeal and determined that the plan is required to cover Alecensa 150 milligram capsule.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Epclusa 400/100 milligram tablets prescribed for chronic hepatitis C virus infection. 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 enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee was prescribed Epclusa for chronic hepatitis C virus infection genotype 1A. Furthermore, the hepatitis C virus infection was confirmed by the presence of hepatitis C virus ribonucleic acid in serum. The drug at issue is to be used as a monotherapy in a treatment naive enrollee.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% ointment prescribed as directed. 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. At coverage determination, a diagnosis of diabetic neuropathy was provided. At redetermination, a diagnosis of hereditary and idiopathic neuropathy was provided. However, the Medicare approved compendia do not support the use of this drug, in this form, for the enrollees conditions. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine ointment 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligram per milliliter to treat the enrollees condition. 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: Unfavorable

At issue is Gammagard Solution 10 grams/100 milliliters. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited 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. We determined that the drug is not eligible for Part D coverage. The Medicare approved compendia do not support the use of this drug for this condition. 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 requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Victoza 0.6 milligram /0.1 milliliter pen injector prescribed for type 2 diabetes. The Part D plan denied your request for a tiering exception because Victoza is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Victoza is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception. Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Megestrol acetate 400 milligram per 10 milliliters oral suspension prescribed to treat the diagnoses of chronically underweight due to multiple medical conditions and common variable immunodeficiency. 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 use of the requested drug to treat the provided diagnoses 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 the enrollees conditions. 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 Megestrol acetate 400 milligram per 10 milliliters oral suspension.