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

At issue is Oxycodone Hydrochloride 80 milligram extended-release oral tablet prescribed daily for pain due to sickle-C 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.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.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 Oxycodone Hydrochloride.
Appeal type: Prescription Drug
Decision: Favorable

You requested Mycophenolate Mofetil 250 milligram capsules prescribed as directed following liver and kidney transplants. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We determined that the drug is not eligible for Part B coverage. Medicare enrollment records show the enrollee was entitled to Medicare Part A coverage on August 1, 2020. The medical records show the enrollee received the liver and kidney transplants on July 6, 2020, and July 7, 2020. The prescriber has also submitted documentation showing that the transplants were covered by the enrollees prior insurer.The documentation shows the doctor prescribed Mycophenolate Mofetil, in combination with Prednisone, following liver and kidney transplants. The Medicare approved compendia support the use of the requested drug for the enrollees condition. Furthermore, the drug is on the plans formulary and does not have prior authorization criteria.A physician reviewed your appeal and determined that the plan is required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Favorable

You requested Prednisone 5 milligram tablets prescribed as directed following liver and kidney transplants. 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 available. We also researched Medicare systems and reviewed the enrollment data available.We determined that the drug is not eligible for Part B coverage. Medicare enrollment records show the enrollee was entitled to Medicare Part A coverage on August 1, 2020. The medical records show the enrollee received the liver and kidney transplants on July 6, 2020, and July 7, 2020. The prescriber has also submitted documentation showing that the transplants were covered by the enrollees prior insurer.The documentation shows the doctor prescribed Prednisone, in combination with Mycophenolate Mofetil, following liver and kidney transplants. The Medicare approved compendia support the use of the requested drug for the enrollees condition. Furthermore, the drug is on the plans formulary and does not have prior authorization criteria.A physician reviewed your appeal and determined that the plan is required to cover Prednisone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch to treat osteoarthritis of the knees and polyneuropathy.  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 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. The medical records, if provided, do not prove the criteria have been met. This medication is also likely subject to prior authorization criteria. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zestoretic 20-25 milligram oral tablet prescribed daily for essential hypertension. 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 your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.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 Zestoretic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Horizant ER 600 milligram tablets prescribed as directed for restless leg 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. 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 Horizant ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz 5 milligram tablets prescribed as directed for alopecia areata. 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 the doctor prescribed Xeljanz to treat alopecia areata. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine HCL 5 milligram tablet prescribed for back chronic muscle spasms and low back pain. 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 Cyclobenzaprine HCL to treat your back muscle spasms and low back pain. However, the Medicare approved compendia do not support the use of this drug for your condition.  The start date for the requested drug was listed by the prescriber as 4/01/2013.  A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligram tablets prescribed as directed for inflammatory myopathy related to mixed connective tissue 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 the doctor prescribed Mycophenolate Mofetil treat inflammatory myopathy related to mixed connective tissue disease. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nystatin 100,000 units/gram powder prescribed as directed for erythema intertrigo. 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 information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested.The medical records submitted at redetermination show the doctor prescribed Nystatin to treat erythema intertrigo. However, the Medicare approved compendia do not support the use of this drug for that condition. At reconsideration, the prescriber listed an additional diagnosis of cutaneous candidiasis. Medical records were not submitted to support the new diagnosis. It could not be determined whether the requested drug was prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Nystatin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin ER 40 milligram tablets prescribed as directed for chronic back pain. 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 the enrollee. It is also noted the prescriber states that one of the formulary alternative medications, Xtampza, is not in stock, or difficult to locate at pharmacies. However, the Food and Drug Administration does not list a current drug shortage for this medication.A physician reviewed your appeal and determined that the plan is not required to cover Oxycontin ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Endari 5 gram oral powder packets prescribed to take 1 packet, by mouth, twice a day to treat complex history of systemic sclerosis with malabsorption of multiple vitamins. 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 Endari 5 gram oral powder packets to treat complex history of systemic sclerosis with malabsorption of multiple vitamins. DRUGDEX shows short bowel syndrome, in conjunction with recombinant human growth hormone, is a Food and Drug Administration medically accepted indication for the requested drug. However, the reconsideration appeal letter indicates a consulting gastroenterologist has diagnosed the enrollee with malabsorption due to short bowel syndrome from severe scleroderma. 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 Endari 5 gram oral powder packets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Botox 200-unit solution reconstituted prescribed as directed for migraine. 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 Botox.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lynparza 150 milligram tablets prescribed as directed for metastatic non-small cell lung cancer. 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 the doctor prescribed Lynparza to treat non-small cell lung cancer. The enrollee was previously treated with Carboplatin, Taxol, and Keytruda. However, the enrollee experienced disease progression. The enrollee was treated with a clinical trial regimen, but experienced disease progression again. Molecular profiling showed the enrollee has a BRCA2 mutation; therefore, the prescriber is now requesting coverage for Lynparza. Medical literature was submitted by the prescriber for review. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.A physician reviewed your appeal and determined that the plan is not required to cover Lynparza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix 50 microgram/0.5 milliliter vaccine prescribed two doses. 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. Shingrix is a biologic drug on Tier 4 of the plans formulary. There are no biologic 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 Tremfya 100 milligram/milliliter injector prescribed as directed for psoriasis vulgaris. 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, your doctor indicates you tried and failed alclometasone, Fluticasone, Triamcinolone, and Taltz. However, 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 Tremfya.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of a Freestyle Libre 14-Day Sensor continuous glucose monitor prescribed for type 2 diabetes mellitus with diabetic neuropathy. The Part D plan your request for coverage.  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.Continuous glucose monitors are classified by the United States by the Food and Drug Administration as medical devices. As such, they do not not meet the definition of a Part D drug. Furthermore, continuous glucose monitors are durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as continuous glucose monitors. Coverage under Part D is excluded for any drug or item for which payment would be available under Part B. Therefore, the continuous glucose monitor is not eligible for coverage under Medicare Part D, as it is classified as a medical device and does not meet the definition of a Part D drug. Furthermore, being durable medical equipment, coverage for the device is available under Medicare Part B. This decision does not address the medical necessity or appropriateness of the requested item. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulance 3 milligram tablets prescribed for chronic idiopathic constipation. 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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Trulance.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gammagard 10% intravenous immunoglobulin solution prescribed for COVID encephalopathy. 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 Gammagard for COVID encephalopathy. The Medicare approved compendia do not support the use of the biologic at issue for your conditions. 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

You requested Ketoconazole 200 milligram tablets prescribed daily for erythema intertrigo. 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 Ketoconazole to treat your erythema intertrigo. 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 Ketoconazole.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Uceris 2 milligram/actuation rectal foam prescribed for ulcerative colitis. 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 your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. A physician reviewed your appeal and determined that the plan is not required to cover Uceris.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Octreotide Acetate 100 micrograms/milliliter for subcutaneous injection prescribed as directed for gastrointestinal bleeding related to angiodysplasia. 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 the doctor prescribed Octreotide Acetate to treat gastrointestinal bleeding related to angiodysplasia. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Octreotide Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trim-San gel 0.025-0.01 % gel prescribed for uterovaginal prolapse and encounter for fitting and adjustment of a urinary device. 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.Non-FDA approved drugs are excluded from Medicare Part D coverage. Per the Medicare-approved compendia, Not for use as a drug. Not for administration to humans. Therefore, the Trim-San is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablets to treat inappropriate sinus tachycardia.  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, as ordered, is not being used for a medically accepted indication. The requested drug is not eligible for coverage under Medicare Part D.