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

You requested Promethazine HCl 25 milligram tablets prescribed for nausea following chemotherapy. The Part D plan denied your request because the 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. The submitted documentation indicates your doctor prescribed Promethazine HCl for nausea following chemotherapy. The Medicare approved compendia do not support the use of this drug for your condition. 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

You requested Diclofenac Sodium 1% gel prescribed for pain in unspecified knee. The Part D plan denied your request. 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. The submitted documentation indicates your doctor prescribed Diclofenac Sodium gel for pain in unspecified knee. Your doctor indicated your symptoms were revised and indicated you have osteoarthritis; however, the medical records submitted do not support a change in diagnosis.  The provided medical records do not substantiate a diagnosis of osteoarthritis. The Medicare approved compendia do not support the use of this drug for your condition. 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

You requested Prodigy no coding blood glucose strips prescribed for diabetes. The Part D plan denied your request because glucose testing supplies are covered under Part B. We received a reconsideration 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 Prodigy no coding blood glucose test strips because they are not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. 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

You requested Prodigy voice glucometer prescribed for diabetes. The Part D plan denied your request because testing supplies are covered under Part B. We received a reconsideration 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 Prodigy voice glucometer because it is not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. 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: Favorable

You requested Mycophenolate Mofetil 250 milligram capsules prescribed for immunosuppression following a lung transplant. The Part D plan denied your request because the 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. We also researched Medicare systems and reviewed the enrollment data available.The submitted documentation indicates your doctor prescribed Mycophenolate Mofetil for immunosuppression following a lung transplant. The Medicare approved compendium, American Hospital Formulary Service Drug Information, contains a citation to support the use of the drug for your condition. In addition, a review of Medicare records indicates the drug at issue is not eligible for Medicare Part B coverage. As the drug was prescribed for a medically accepted indication, coverage can be allowed.A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Pushtronex System 120 milligrams/milliliter for subcutaneous injection prescribed as directed for hypercholesterolemia. The Part D plan denied coverage because the prior authorization criteria were not met. 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 records submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollee. We also asked for medical records or other documentation to show why the enrollee needs this medication. We received some of the documentation requested and included it in our review.The documentation shows the doctor prescribed Repatha for hypercholesterolemia. However, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Favorable

You requested Budesonide 3 milligram tablets prescribed twice daily for microscopic colitis. The Part D plan denied your request. 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. The submitted documentation indicates your doctor prescribed Budesonide for microscopic colitis. The Medicare approved compendia support the use of this drug for your condition. As the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Arikayce 590 milligram\8.4 milliliter vial prescribed as directed for pulmonary mycobacterial abscessus complex and pseudomonas and serratia marcensus. The Part D plan denied your request because the drug is not 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 Arikayce 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 Arikayce.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxandrolone 2.5 milligram tablets prescribed as an appetite stimulant. 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.We determined that the plan is not required to cover Oxandrolone because it was prescribed as an appetite stimulant to increase weight. Drugs to treat anorexia, weight loss, or weight gain 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 Lidocaine 5% patch to treat back pain. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. This drug requires very specific criteria to be met in order to be considered a medically accepted indication. It is also likely subject to prior authorization criteria. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our physician reviewer's opinion is that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Galantamine Hydrobromide ER capsules to treat Alzheimers dementia. The Part D plan denied your request for a tiering exception. 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. Galantamine Hydrobromide ER is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated why all other 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, a tiering exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Benztropine mesylate 2 mg tablets to treat extrapyramidal symptoms secondary to antipsychotic medications. 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. The documentation satisfies the plans coverage criteria.  The patient has been using this drug without adverse consequence in addition to the alternative amantadine in order to control symptoms. The January 6, 2021 office note indicates discussion was undertaken regarding medication side effects and risks. 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 Edarbi 80 milligram tablets prescribed for hypertension. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Edarbi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 20 milligram tablet 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.Xarelto 20 milligram tablet 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 Mycophenolate Mofetil 500 milligram tablets to treat sicca syndrome. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Arikayce 590 milligram/8.4 milliliter inhalation suspension prescribed for mycobacterium avium complex infection. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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.The record shows your doctor prescribed Arikayce for mycobacterium avium complex infection. The medication is to be used via a nebulizer. Drugs used via a nebulizer in the home setting are available for coverage under Medicare Part B. Therefore, this is not covered by Part D.We determined that the plan is not required to cover Arikayce.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xopenex HFA to treat asthma. The Part D plan denied your request for a non-formulary exception. We received an expedited 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 records submitted at the reconsideration level. The prescriber has not indicated why all alternatives which are 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 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 Naproxen/Esomeprazole magnesium 375/20 milligram tablets to treat the diagnosis of osteoarthritis. 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.Naproxen/Esomeprazole magnesium is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain 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 coverage criteria is not supported.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Venclexta 100 milligram tablets prescribed as directed for high risk myelodysplastic 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. We asked the prescriber to send us additional medical records showing the enrollees need for this medication. However, we did not receive the documentation.The prescriber statement shows the enrollee is being prescribed Venclexta for high risk myelodysplastic syndrome. However, the medical records provided show the enrollee is being prescribed Revlimid due to 5q deletion. 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 Venclexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cosentyx 150 milligram/milliliter pen injector prescribed for the enrollees psoriatic arthritis. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription biologics. If prior approval is not obtained, the plan may not cover the biologic. 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 records submitted at the reconsideration level. The documentation supports the biologic was prescribed for the enrollees diagnosis of psoriatic arthritis. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Freestyle Libre 2 Sensors prescribed for type I diabetes mellitus. 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.Supplies for testing and monitoring blood glucose levels are not considered Part D drugs and may be covered under the Medicare Part B durable medical equipment benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vraylar 1.5 milligram capsule prescribed as directed for autistic disorder, generalized anxiety disorder, and unspecified mood disorder. The Part D plan denied the request because it does not meet the criteria of 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. The record shows you were prescribed Vraylar to treat your condition. However, the Medicare approved compendia do not support the use of this drug for your 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 Vraylar because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80 milligram/milliliter pen injector prescribed for the enrollees plaque psoriasis. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription biologics. If prior approval is not obtained, the plan may not cover the biologic. 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 records submitted at the reconsideration level. The documentation supports the biologic was prescribed for the enrollees diagnosis of plaque psoriasis. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temazepam 22.5 milligram tablets daily for 90 days to treat insomnia. The Part D plan denied the request.  The requested drug is not on the plans formulary. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The 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 or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. In addition, a Tier 4 approved formulary exception is only available as a 30-day supply. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 49-51 milligram tablets prescribed twice daily for congestive heart failure. The Part D plan denied your request for a tiering exception.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.Entresto 49-51 milligram tablet 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.Our Physician Reviewer's opinion is that tiering exception criteria are not met.