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

You requested Brovana 15 micrograms/2 milliliter nebulizer solution prescribed as directed for chronic obstructive pulmonary disease. 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 Brovana nebulizer solution to treat your chronic obstructive pulmonary disease. However, we determined that the drug is not eligible for Part D coverage. 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 Brovana nebulizer solution 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 Brovana nebulizer solution to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent topical patch prescribed for primary osteoarthritis right wrist. 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. 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 Lidocaine 5 percent topical patch for primary osteoarthritis right wrist.In review of the Medicare approved compendia, primary osteoarthritis right wrist is not a medically accepted indication for Lidocaine 5 percent topical patch as prescribed. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Lidocaine 5 percent topical patch at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ofev 150 milligram capsules prescribed twice daily for idiopathic pulmonary fibrosis. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. 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. 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. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that a tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Acitretin 25 milligram tablets prescribed daily for hidradenitis suppurativa. The Part D plan denied your request because the provide diagnosis 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Acitretin to treat your hidradenitis suppurativa. 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 Acitretin because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Cypionate Solution to treat testosterone deficiency. The Part D plan denied coverage because there was insufficient documentation to support that the prior authorization criteria were met. 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 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 your appeal and determined that the plan is not required to cover Testosterone Cypionate Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide Ampule Nebulizer Solution 0.25 milligram/2-milliliter. 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 also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram/milliliter injection pen prescribed for atherosclerotic heart disease of native coronary artery without angina pectoris. 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. Your physician submitted a supporting statement. The supporting statement did not indicate all 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 Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium Gel 3%. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The physician submitted a supporting statement. The prescriber statement indicates that Diclofenac Sodium Gel 3% is prescribed to treat severe knee pain due to osteoarthritis. The enrollee has tried and failed two oral nonsteroidal anti-inflammatory drugs. However, medical records have not been submitted for review. Therefore, the documentation available 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 Diclofenac Sodium Gel 3%.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Kineret 100 milligram/0.57 milliliter subcutaneous solution prescribed for acute nonspecific idiopathic pericarditis. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Kineret for acute nonspecific idiopathic pericarditis. The Medicare approved compendia do not support the use of this biologic for your condition. As the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humalog 100 units/milliliters dispensed by a disposable insulin pump prescribed for diabetes mellitus. 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. We determined that the drug is not eligible for Part D coverage. Drugs administered by a disposable insulin pump are covered by Part B. 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 Humalog. You may wish to submit a request for Humalog to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dalfampridine 10 milligrams prescribed as directed for multiple sclerosis. The Part D plan denied coverage because the plan requires prior authorization 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. Your medical records show you were prescribed Dalfampridine for 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 the Dalfampridine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Leflunomide 20 milligram tablet prescribed as directed to treat rheumatoid arthritis. The Part D plan denied the request. 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 prescriber has not indicated that you have tried all alternatives required by the plan, 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

At issue is a tiering exception request for Dilantin 100 milligram capsule prescribed as directed to treat epilepsy. The Part D plan denied the request. 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.Dilantin 100 milligram capsule is a brand drug on Tier 4 of the plans formulary. There are no brand name drugs on lower tiers to treat your condition. Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rybelsus 3 milligrams. The Part D plan denied the request. 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.No medical records were provided by the prescriber. 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 the Rybelsus because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Favorable

You requested four tablets for a 30 day supply of Promacta 25 milligrams prescribed for thrombocytopenia. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates your doctor prescribed Promacta for thrombocytopenia. The Medicare approved compendia support the use of the drug at issue for your condition. Your doctor submitted a supporting statement that indicated you take one tablet a week and requested four tablets for a 30 day supply. Your plan allows 30 tablets per 30 days. You are not requesting a quantity greater than the plans criteria.Therefore, the plan is required to cover Promacta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisone 5 milligram tablets 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 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 medical records show the requested drug is being prescribed to treat the enrollees condition. The enrollees medical history includes a kidney transplant in March 1999. According to Medicare, the enrollee was under Medicare Part A coverage at the time of the transplant. Based on the information provided, we have determined the requested drug is not eligible for Medicare Part D coverage, but would be covered under Part B.A physician reviewed your appeal and determined that the requested drug is not eligible for Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus 1 milligram capsules 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 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 medical records show the requested drug is being prescribed to treat the enrollees condition. The enrollees medical history includes a kidney transplant in March 1999. According to Medicare, the enrollee was under Medicare Part A coverage at the time of the transplant. Based on the information provided, we have determined the requested drug is not eligible for Medicare Part D coverage, but would be covered under Part B.A physician reviewed your appeal and determined that the requested drug is not eligible for Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate 500 milligram tablets to treat the enrollees condition. 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 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.The medical records show the requested drug is being prescribed to treat the enrollees condition. The enrollees medical history includes a kidney transplant in March 1999. According to Medicare, the enrollee was under Medicare Part A coverage at the time of the transplant. Based on the information provided, we have determined the requested drug is not eligible for Medicare Part D coverage, but would be covered under Part B.A physician reviewed your appeal and determined that the requested drug is not eligible for Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aranesp 40 micrograms per 0.4 milliliter syringe every week to treat anemia related to end stage renal disease. 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 states all formulary alternatives required by the plan would likely be as effective as the requested drug. Therefore, an exception is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue Gammaplex 10% injection 20 milligram/200 milliliters prescribed to treat chronic sensory demyelinating polyneuropathy. The Part D plan denied the request. We received a standard 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. The plan requires prior authorization that includes confirmation of the diagnosis of chronic inflammatory demyelinating polyneuropathy by progressive symptoms, progressive or relapsing motor and sensory impairment of more than one limb and electrophysiologic findings of partial conduction block of one or more motor nerves, reduced conduction velocity of two or more motor nerves, prolonged distal latency of two or more motor nerves or prolonged F-wave latencies of two or more motor nerves or the absence of F waves. The prior authorization rules were not met.A physician reviewed your appeal and determined that the plan is not required to cover Gammaplex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligrams to treat erectile dysfunction. The Part D Plan denied the 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. This includes the case file from the plan, and any information submitted at the reconsideration level.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myfortic 180 milligram tablets prescribed daily 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. We also researched Medicare systems and reviewed the enrollment data available. Your records show your doctor prescribed Myfortic to prevent rejection following a kidney transplant. The Medicare approved compendia support the use of this drug for your condition. Based on the information provided, the drug is eligible for Part B coverage.  Therefore, the drug is not eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is not required to cover Myfortic.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rituxan 500 milligram/50 milliliter vial prescribed for membranous nephropathy. 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 provided shows Rituxan was supplied by you and administered to the enrollee in your office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. 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 Rituxan. 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

You requested Amphetamine/Dextroamphetamine 20-milligram tablets prescribed for fatigue due to multiple sclerosis. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 you were prescribed Amphetamine/Dextroamphetamine for fatigue due to multiple sclerosis.In review of the Medicare approved compendia, fatigue due to multiple sclerosis is not a medically accepted indication for Amphetamine/Dextroamphetamine. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Amphetamine/Dextroamphetamine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 3% gel to treat the enrollees right shoulder pain. 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 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.