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

You requested Brukinsa 80 milligram capsules prescribed four times daily for relapsed Waldenstrom macroglobulinemia for an enrollee with a history of severe subdural hematoma. The Part D plan denied your request because the medication is 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. This includes the case file from the plan and any information submitted at the reconsideration level. The records show you prescribed Brukinsa to treat the enrollees relapsed Waldenstrom macroglobulinemia. Medicare approved peer reviewed medical literature do support the use of this drug for this condition. Specifically, three studies were included in documentation supporting use in Phase 1 and 2 trial, Zanubrutinib showed deep durable responses, improved safety and efficacy over standard of care. Zanubrutinib has been shown to have same efficacy as ibrutinib in Phase 3 trial with less adverse effects including risk of bleeding (hemorrhage) and pneumonia. The enrollee is at risk of both of these complications. Thus, this medication will provide similar efficacy while minimizing adverse events. A oncologist reviewed your appeal and determined that the plan is required to cover Brukinsa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amitiza 24 microgram capsules 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 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.Amitiza is a brand drug on Tier 4 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 Tresiba 100 unit/milliter to treat the enrollees condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% Topical Patch prescribed apply one daily for osteoarthritis and lumbar radiculopathy. The Part D plan denied your request because diagnoses provided did not meet the requirements of Food and Drug Administration medically accepted indications. 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 your doctor prescribed Lidocaine 5% Topical Patch to treat your osteoarthritis and lumbar radiculopathy. However, the Medicare approved compendium does not support the use of this drug for your conditions. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% Topical Patch because your diagnoses do not meet the Medicare requirement of medically accepted indications.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humira 40 milligram/milliliter injection kit for Rasmussens syndrome. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates Humira was prescribed for Rasmussens syndrome. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent patch prescribed as needed for osteoarthritis, degenerative disc disease lumbar, and fibromyalgia. The Part D plan denied your 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Lidocaine 5 percent patch as needed to treat your osteoarthritis, degenerative disc disease lumbar, and fibromyalgia. 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 Lidocaine 5 percent patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 3% topical gel prescribed for ankle pain. 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. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Diclofenac Sodium for ankle pain. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Botox 100 units intramuscular powder for solution to treat muscle spasticity. 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 prescriber has not indicated 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. The plan documents that you did try and fail Baclofen.  However, the medical records received do not support that at least two formulary alternatives were tried.  Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium CitrateCitric Acid Solution, 1100 milligrams-334 milligrams per 5 milliliters to treat nephrolithiasis and hypercalciuria.   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.Non-FDA approved drugs are excluded from Medicare Part D coverage.  Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Austedo 12 milligram tablets twice daily prescribed for tardive dyskinesia. The Part D plan denied coverage because prior authorization requirements were not met. 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. The documentation supports the drug was prescribed for the enrollees diagnosis of tardive dyskinesia. The plan has prior authorization coverage criteria that are satisfied by the records provided at reconsideration. The scores provided on the Abnormal Involuntary Movement Scale (AIMS) shows your score was 11 on November 15, 2020 compared to your baseline  AIMS score of 15 prior to beginning Austedo. Therefore, coverage can be provided.A physician reviewed your appeal and determined that Austedo is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nulojix 500 milligrams, intravenous solution prescribed every four weeks for transplant anti-rejection. 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. The record shows the Nulojix is prescribed for transplant anti-rejection after your kidney transplant on October 9, 2019. Medicare records show you were enrolled in Medicare Part effective June 1, 2013. The Medicare Part D Prescription Drug benefit does not cover drugs that are covered under the Medicare Part B End-Stage Renal Disease benefit. We determined that the plan is not required to cover Nulojix. Medicare Part B is responsible for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Kineret 100 milligrams/0.67 milliliters syringe prescribed daily for pericarditis. The Part D plan denied your 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Kineret 100 milligrams/0.67 milliliters syringe daily to treat your pericarditis. 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 Kineret 100 milligrams/0.67 milliliters syringe because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dutasteride 0.5 milligrams capsule to treat benign prostatic hyperplasia. 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 prescriber has not indicated why other alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, a tiering exception to the plans coverage criteria is not supported. A physician reviewed your appeal and determined that the plan is not required to cover Dutasteride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zelnorm (Tegaserod Maleate) 6-milligram tablet prescribed one daily for irritable bowel syndrome with constipation. The Part D plan denied the appeal because the drug is a benefit exclusion under the Medicare Part D benefit. This means that Medicare Prescription Drug Plans cannot cover (pay for) this prescription drug at all, or give an 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 record shows that your doctor prescribed Zelnorm for your irritable bowel syndrome with constipation. Zelnorm is excluded from coverage under the Medicare Part D benefit because there are no conditions under which this request would be approved under Medicare Part D. This is not to say that this drug does not benefit you, just that Medicare does not allow this drug for any condition or give an exception under the Medicare Part D benefit. We have determined that your plan is not required to cover Zelnorm because Medicare has excluded this drug from coverage under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Leflunomide 20 milligram tablets to treat the enrollees condition.   The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.  Leflunomide 20 milligram tablets is a generic drug on Tier 3 of the plans formulary. 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

You requested Vemlidy, 25 milligram tablets for a 90-day supply, prescribed for hepatitis B. The Part D plan denied your request for a 90-day supply because Vemlidy is not on the plans formulary, and therefore, is a specialty drug. A specialty drug will only be approved by the plan for a recurring 30-day supply.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 a 90-day supply of Vemlidy, as the drug exceeds the number of doses that may be dispensed during a specific period of time.The Part D plan only allows a 30-day supply at a time. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover a 90-day supply of Vemlidy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Symbicort 160/4.5 micrograms aerosol 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. The documentation indicates the physician had prescribed Symbicort to treat chronic obstructive pulmonary disease. However, the records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. The physician did not indicate all alternatives on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Symbicort.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Glucagon 1 milligram emergency kit for hypoglycemia. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Glucagon emergency kit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100 microgram/62.5 microgram/25 microgram inhalation powder prescribed 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 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.Trelegy Ellipta 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

You requested Diclofenac Sodium 1% gel prescribed for acute pain of right knee. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Diclofenac Sodium for acute pain of right knee. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chantix 1 milligram prescribed twice daily for nicotine dependence. The Part D plan denied your request for a tiering exception because there were no brand drugs on the lower tiers for this 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.Chantix is a brand drug on Tier 4 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 Incruse Ellipta 62.5 microgram inhalation powder prescribed 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 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.Incruse Ellipta 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 Gralise 600 milligram tablet prescribed for disorder of the autonomic nervous system and trigeminal neuralgia. The Part D plan denied your request for a non-formulary drug. The plan indicated 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 documentation shows Gralise was prescribed to treat peripheral neuropathy and trigeminal neuralgia. However, the Medicare approved compendia do not support the use of this specific drug dosage for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to cover Gralise.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine HCL 8 milligram sublingual tablet prescribed for radiculopathy of the lumbar region. The Part D plan denied the request. We received an expedited 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. Medicare approved compendia do support the use of this medication for the diagnoses submitted. Therefore, it is considered a medically accepted indication. However, the plan has prior authorization coverage criteria that are not satisfied by the records provided. Therefore, coverage cannot be provided.A physician reviewed your appeal and determined that the plan is not required to cover the Buprenorphine HCL.