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

At issue is Aubagio 14 milligram tablets prescribed for multiple sclerosis. 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 documentation indicates the physician had prescribed Aubagio to treat your multiple sclerosis. The Medicare approved compendia support the use of the requested drug for your condition.However, 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 Aubagio.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets prescribed as directed. The Part D plan denied coverage because the prior authorization criteria were not met. Specifically, the prescriber indicated that the enrollee already received an initial 14-day course of treatment, as well as two additional 14-day courses of treatment with the drug at issue. 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 prescriber statement submitted to the Part D plan indicates the enrollee was treated with Xifaxan for irritable bowel syndrome. The prescriber statement submitted at reconsideration shows the enrollee was prescribed Xifaxan to reduce the risk of hepatic encephalopathy recurrence. The Medicare approved compendium does support the use of Xifaxan for either condition.The prescriber statement submitted to the Part D plan during the initial coverage determination states the enrollee already received an initial 14-day course of treatment and two additional 14-day courses of treatment with the drug at issue. The prescriber statement submitted at reconsideration does not address the previous use of the drug. The reconsideration request form also states that the enrollee was on this drug for quite a while. Medical records have not been submitted for review. The documentation submitted provides conflicting information. The documentation 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Levalbuterol HCl 1.25 milligrams/3 milliliters solution prescribed daily for hypoxemia and cerebral palsy. 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 medical records show Levalbuterol HCl was prescribed to treat hypoxemia and cerebral palsy. 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 Levalbuterol HCl. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Balversa tablet prescribed for stage IV squamous cell carcinoma of the lung. The Part D plan denied a request for coverage because you did not have a medically accepted indication for this drug. We received a reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows Balversa was prescribed to treat lung cancer. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Balversa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hetlioz 20 milligrams prescribed for circadian rhythm sleep disorder, free running type (G47.24). The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. 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 including case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Hetlioz to treat your circadian rhythm sleep disorder, free running type. 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 Heltioz as it is not eligible for coverage under Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Breztri 160 microgram inhalation prescribed for chronic obstructive pulmonary disease. 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 documentation indicates the physician had prescribed Breztri to treat your chronic obstructive pulmonary disease. The Medicare approved compendia support the use of the requested drug for your condition.However, 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 Bretzri.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cimzia starter kit 6 x 200 milligrams prescribed for spondylosis. The Part D plan denied the request because you have primary pharmacy benefit coverage through another plan. We received an auto-forwarded request from the Plan to reconsider the appeal.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 that you are enrolled in a primary insurance plan that is not Medicare Part D. The pharmacy should bill the prescription for Cimzia to the primary plan before billing Medicare Part D. The Medicare Part D Plan is not required to process the claim until after your primary insurance has processed it. We have determined that the plan is not required to allow coverage as secondary payer. You may resubmit your claim to your Part D plan once your primary insurance has processed it.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets prescribed twice daily for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. 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.Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. 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 a tiering exception request for Pristiq ER 50 mg to treat bipolar disorder and post traumatic stress disorder. 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 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 your plan under a formulary exception. Pristiq ER is not on the plans formulary. However, they have agreed to provide it at a cost sharing level for all formulary exceptions. Per Medicare rules, non-formulary drugs cannot be granted a tiering exception.  Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle Libre 14 day Sensor prescribed by your doctor for monitoring glucose level. The Part D plan denied your request because this drug does not meet the definition of a Part D drug. We received a reconsideration request. We performed and 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 Freestyle Libre 14 day Sensor because Medicare law does not allow certain drugs or classes of drug to be covered under your Part D pharmacy benefit. Medicare rules state that the definition of a Part D drug includes medical supplies directly associated with the injection of insulin. Test strips, lancets and needle disposal systems are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. Therefore, the Freestyle Libre 14 day Sensor is excluded from coverage under the Part D benefit. 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 prescribed Intron A/Eyes Alive Eye Wash Compound Solution 10000000 units for the treatment of malignant neoplasm of left conjunctiva. The Plan allowed payment for the drug component Intron A. The compound ingredient was denied because it does not meet the definition of a Part D drug. 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 medical records show Intron A/Eyes Alive Eye Wash was prescribed to treat malignant neoplasm of left conjunctiva. However, according to Medicare the compound ingredient does not meet the definition of a Part D drug. A physician reviewed your appeal and determined that the plan is not required to cover Eyes Alive Eye Wash.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vimpat, 50 milligram tablets prescribed for epilepsy. The Part D Plan denied your request for a tiering exception because there were no other brand drugs appropriate to treat your condition on a lower cost-sharing tier. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Vimpat at a lower cost tier.Vimpat is a brand name drug on Tier 3 of the plans formulary. There are no brand name drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Ztlido 1.8 percent film prescribed for hip and back pain after a lung transplant. The Part D plan denied your request for a 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 information submitted at the reconsideration level. The record shows you were prescribed Ztlido to treat your hip and back pain. The Medicare approved compendia does not support the use of this drug, as prescribed, for your condition. Your doctor submitted a prescriber statement indicating that you require the medication because you are looking for a non-narcotic form of pain relief. However, this form of medication is not included in the plan formulary. The formulary includes other drugs that could be used to treat your condition. Your records do not show that all alternative drugs on the plan formulary have been tried or why you cannot take them. This decision does not address the medical necessity of the requested drug. It only means that it cannot grant a formulary exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate 250 milligrams prescribed as directed for a lung transplant. 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 Mycophenolate for a lung transplant. 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 Mycophenolate because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis 0.05% emulsion prescribed twice daily for chronic dry eyes. The Part D plan denied your request for a tiering exception because there are no lower tier alternative for your condition. 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.Restasis 0.05% emulsion is a covered brand drug on Tier 3 of the plans formulary. However, 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 Dexilant Delayed Release, 30 milligrams one tablet prescribed once daily for gastroesophageal reflux disease without esophagitis. You asked the Part D plan to provide a tiering exception. Your plan approved the use of the brand named drug Dexilant Delayed Release, Tier 4, for your condition. Your plan does not include other brand name drugs on the lower cost-sharing tiers to treat your condition. As such, your drug was excluded from a cost-sharing tier 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 records show Dexilant Delayed Release is being prescribed for gastroesophageal reflux disease without esophagitis. A Medicare approved compendium supports the use of the requested drug for your condition. There are no brand name drugs of the same type on the lower cost-sharing tiers to treat your condition. Therefore, the requested drug is not eligible for a cost-sharing tiering exception.A physician reviewed your appeal and determined that you plan is not required to cover Dexilant Delayed Release as a cost-sharing tier exception because there are no brand name drugs on the lower tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium-Albuterol, 0.5-3 milligrams in 3 milliliter ampules, prescribed for the treatment of chronic obstructive pulmonary disease. The Part D plan denied the request because drugs that can 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 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 that the Ipratropium-Albuterol is being administered to the enrollee via a nebulizer. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment. 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. Therefore, 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 Ipratropium-Albuterol. 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.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Northera 100 milligrams ordered three times daily for neurogenic orthostatic hypotension. The Part D plan denied the request because the records did not support why the preferred drug Fludrocortisone would not work just as well. 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.A supporting statement and medical records were submitted. The records show Northera was ordered to treat the enrollees condition. The Medicare approved compendium support the use of the drug for this condition.The records show that the enrollee cannot take other drugs on the plans formulary for this condition. Specifically, Fludrocortisone caused a hypertensive emergency and hypokalemia.A physician reviewed your appeal and determined that the plan is required to cover Northera.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine 10 milligrams prescribed daily for the enrollees anxiety. The Part D plan denied coverage 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 records submitted at the reconsideration level. Your physician originally provided the diagnosis of insomnia, which is not a medically accepted indication. The physician submitted a statement and medical records to support your diagnosis of anxiety. The diagnosis of anxiety is a medically accepted indication. However, you do not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated you have tried at least two alternative drugs for your condition.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 Vesicare 10 milligram tablet prescribed for multiple sclerosis. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization requirements be met before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Vesicare. The medical records show that Vesicare was prescribed to treat the enrollees multiple sclerosis. The Medicare approved compendia do not support the use of this drug for multiple sclerosis. Therefore, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria for prior authorization.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hizentra 2 grams/10 milliliters prescribed as directed for selective deficiency of immunoglobulin G. 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 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 Hizentra 2 grams/10 milliliters to treat your selective deficiency of immunoglobulin G. The Medicare approved compendia do support the use of this drug for your condition. However, we determined that the drug is not eligible for Part D coverage. Medicare Part B provides coverage of IVIG for the treatment of primary immune deficiency diseases (ICD-10 diagnosis codes D80.0, D80.2, D80.3, D80.4, D80.5, D80.6, D80.7, D81.0, D81.1, D81.2, D81.5, D81.6, D81.7, D81.89, D81.9, D82.0, D82.1, D82.4, D83.0, D83.1, D83.2, D83.8, D83.9, G11.3) in the home. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. 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 Hizentra 2 grams/10 milliliters because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit.You may wish to submit a request for Hizentra 2 grams/10 milliliters to the Medicare Part B carrier.