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

The enrollee requested Gabapentin 100 milligram tablet. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee received Gabapentin as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a hospital statement and receipt showing payment was made for the drugs. The National Drug Code provided has been verified with the Food and Drug Administration as a valid code. However, the prescribers name and National Provider Identifier (NPI) number of the prescriber is missing. Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Lisinopril 20 milligram tablet. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee received Lisinopril as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a hospital statement and receipt showing payment was made for the drugs. The National Drug Code provided has been verified with the Food and Drug Administration as a valid code. However, the prescribers name and National Provider Identifier (NPI) number of the prescriber is missing. Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Pantoprazole Sodium DR 40 milligram tablet. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee received Pantoprazole Sodium as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a hospital statement and receipt showing payment was made for the drugs. The National Drug Code provided has been verified with the Food and Drug Administration as a valid code. However, the prescribers name and National Provider Identifier (NPI) number of the prescriber is missing. Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Evenity 210 milligram dose prescribed as directed for age-related osteoporosis. 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 Evenity.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ilaris 150 milligram/milliliter vial prescribed for calcium pyrophosphate deposition disease. 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 Ilaris was prescribed to treat calcium pyrophosphate deposition disease. 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 Ilaris.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluoxetine 10 milligram tablets prescribed to take 1 tablet, by mouth, every day to treat generalized anxiety disorder.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 shows the doctor prescribed Fluoxetine 10 milligram tablets to treat generalized anxiety disorder. 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 the appeal and determined that the plan is not required to cover Fluoxetine 10 milligram tablets.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Lumakras 120 milligram prescribed for metastatic adenocarcinoma of the lung, KRAS mutated. 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 enrollee was diagnosed with metastatic disease and also activity in the lower left lung with pleural effusion making the enrollee a stage 4. The enrollee could not tolerate chemotherapy so Keytruda was started with a second dose due July 29, 2021. Molecular profiling shows KRAS G12C mutation and the enrollee was continuing with shortness of breath and it was stated they would switch to Lumakras when available. Per the Food and Drug Administration, Sotorasib is indicated for the treatment of adult patients with KRAS G12C mutated locally advanced or metastatic non-small cell lung cancer, as determined by a Food and Drug Administration approved test, who have received at least one prior systemic therapy. This indication is approved under accelerated approval based on overall response rate and duration of response. Per the National Comprehensive Cancer Network, category 2A, Lumakras is indicated as subsequent therapy as a single agent for Kras G12C mutation positive recurrent, advanced, or metastatic disease in patients with performance status 0-2. The regulations do not state the enrollee has to have progressed on first line therapy in order to get second line therapy with Lumakras. Compendia and Food and Drug Administration indicates that the enrollee only has to have received a prior therapy, which she has. Lumakras is not on the plans formulary. However, there is no other KRAS inhibitor available for lung cancer, so there are no other alternatives that the enrollee can use in a second line setting. Therefore, a formulary exception can be made. A physician reviewed your appeal and determined that the plan is required to cover Lumakras.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Venclexta 100 milligram tablets prescribed as directed for myelofibrosis and myeloproliferative neoplasm. 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 Venclexta to treat your myelofibrosis and myeloproliferative neoplasm. 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 Venclexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 200 milligram capsules prescribed as directed for chronic low back pain and paresthesias in the legs. 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Pregabalin to treat your chronic low back pain and paresthesias in the legs. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 250 milligram capsule prescribed for myositis-related interstitial lung disease. 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 Mycophenolate Mofetil was prescribed to treat myositis-related interstitial lung disease. 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligram/milliliter pen injector prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Repatha is a biologic on Tier 3 of the plans formulary. There are no biologics of the same type on the lower cost sharing tiers. Therefore, this biologic is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jublia 10% topical solution prescribed for onychomycosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Jublia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Simponi Injector 100 milligram/milliliter prescribed for Crohns disease. 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 records submitted at the reconsideration level. The documentation submitted from the prescriber indicates Simponi is prescribed for Crohns disease. 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 Simponi.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cincaclet HCL 60 milligram tablets prescribed for secondary hyperparathyroidism of renal origin. 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. According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. Drugs which are eligible for Part B coverage are excluded from Part D coverage. We determined that the plan is not required to cover the Cincaclet. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit. In conclusion, our decision is unfavorable.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Bicillin L-A 2,400,000 units injection prescribed for late congential syphilis. The Part D plan denied the enrollees request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows Bicillin L-A injection was administered to the enrollee while in a skilled nursing facility. According to Medicare rules, Part B pays for injectable and infused drugs given by a licensed medical provider that isnt self-administered. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover Bicillin L-A injection. Please submit your request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is OxyCONTIN 10-milligram 12-hour tablet 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. OxyCONTIN is a brand drug on Tier 4 of the plans formulary. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you. 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 Lasix 20 milligram tablets prescribed for congestive heart failure. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. We received the documentation and included it in the review.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Lasix.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Eszopiclone 3 milligram tablets prescribed for insomnia. The Part D plan denied coverage.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 records submitted at the reconsideration level. We requested additional information from the prescriber. Specifically, we requested medical records to support the enrollee met the plans prior authorization coverage criteria. However, we did not receive the requested information.The documentation on hand does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.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 asked for reimbursement for a Shingles vaccine. 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 information provided supports all requirements have been met for reimbursement of a Shingles vaccine. A receipt has been submitted for the amount of $317.00. We have determined that the plan is required to reimburse the amount of the Shingles vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium Bromide-Albuterol Sulfate 0.5/2.5 (3) milligrams/3 milliliter nebulizer solution. 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 drug at issue is for use in a nebulizer in the enrollees home. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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

The enrollee requested Mycophenolic Acid DR 180 milligram capsule prescribed for the prevention of kidney transplant rejection. 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 had a kidney transplant on December 26, 2016. According to Medicare enrollment records, the enrollee was entitled to Medicare Part A coverage at the time of the transplant. Therefore, the transplant is considered a Medicare covered transplant and Mycophenolic Acid DR is eligible for coverage under Medicare Part B. Medicare Part B covers prescription drugs used in immunosuppressive therapy furnished to an enrollee who has received an organ transplant. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. We determined that the Medicare Part D plan is not required to cover Mycophenolic Acid DR. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 1 milligram capsule prescribed to prevent kidney transplant rejection. The Part D plan denied the enrollee's request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the enrollee had a kidney transplant on December 26, 2016. According to Medicare enrollment records, the enrollee was entitled to Medicare Part A coverage at the time of the transplant. Therefore, the transplant is considered a Medicare covered transplant and Tacrolimus is eligible for coverage under Medicare Part B. Medicare Part B covers prescription drugs used in immunosuppressive therapy furnished to an enrollee who has received an organ transplant. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. We determined that the Medicare Part D plan is not required to cover Tacrolimus. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Capecitabine 500 milligram tablet prescribed for treatment of colon cancer. 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. Medicare rules state that drugs taken orally during cancer chemotherapy provided they have the same active ingredients, and are used for the same indications as chemotherapy drugs that would be covered, if they were not self-administered, are covered under Part B. Part D excludes any drug for which payment would be available under Medicare Part A or Part B for that individual. The record shows the drug was prescribed to be used as an orally administered chemotherapy agent. We determined the Part D plan is not required to cover the Capecitabine. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Orphenadrine-ASA-Caffeine tablet 50-770-60 milligram prescribed for myalgia and mild to moderate pain of musculoskeletal disorders. The Part D plan denied your request because the diagnoses submitted are not medically accepted indications. In addition, the requested drug is not listed on the plans formulary. 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 Orphenadrine-ASA-Caffeine was prescribed to treat myalgia and mild to moderate pain of musculoskeletal disorders. However, the Medicare approved compendia do not support the use of this drug for your conditions. Since Orphenadrine-ASA-Caffeine is not eligible for coverage under Part D, the plans formulary exception requirements are not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover Orphenadrine-ASA-Caffeine.