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

You requested coverage for Buprenorphine Hydrochloride 8 milligram sublingual tablets prescribed for chronic pain. The Part D plan denied the request stating that the medication was prescribed for a non-medically accepted indication.  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 submitted at reconsideration indicates that Buprenorphine Hydrochloride sublingual tablets are being prescribed for chronic pain management due to the presence of multiple conditions. However, the Medicare approved compendia do not contain any citations to support the use of Buprenorphine Hydrochloride sublingual tablets for the treatment of chronic pain management. A physician reviewed your appeal and determined that the plan is not required to cover the Buprenorphine Hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 200 milligram tablets prescribed for hypersomnia and central sleep apnea secondary to cerebrovascular accident. 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 Modafinil for hypersomnia and central sleep apnea secondary to cerebrovascular accident.In review of the Medicare approved compendia, hypersomnia and central sleep apnea secondary to cerebrovascular accident is not a medically accepted indication for Modafinil. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Modafinil at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Exemestane 25 milligrams to treat breast cancer. The Part D plan denied your request for a tiering 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. Exemestane is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated why all 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 grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent topical patch prescribed for diabetic neuropathy. 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 diabetic neuropathy.In review of the Medicare approved compendia, diabetic neuropathy 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 Azathioprine 50 milligrams tablets. 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 Azathioprine is prescribed to treat autoimmune hemolytic anemia. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s).A physician reviewed your appeal and determined that the plan is not required to Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Tirosint 50 microgram capsules prescribed for unspecified hypothyroidism. 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 a tier exception for Jardiance 10 milligram oral tablets prescribed daily for type 2 diabetes. The Part D plan denied your request for a tiering exception because Jardiance is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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 plan shows Jardiance is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omega 3-Acid 1-gram capsule to treat hyperlipidemia. 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 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.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipratropium-Albuterol 0.5 milligrams per 3 milliliter ampule prescribed via nebulizer for asthma. 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 doctor prescribed Ipratropium-Albuterol for asthma. However, this drug is eligible for coverage under Medicare Part B. Medicare Part B covers this drug for asthma, when used with a nebulizer in the home (or in an assisted living facility). Medicare Part D cannot pay for drugs that are covered by Medicare Part B.We reviewed your appeal and determined that the plan is not required to cover Ipratropium-Albuterol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 49-51 milligram tablets prescribed twice daily for the enrollees condition. 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.Entresto 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 Megestrol Acetate 20 milligram tablets prescribed twice daily for cachexia due to pulmonary hypertension. 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 Megestrol Acetate for cachexia due to pulmonary hypertension. 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 prescribed Gattex 5 milligram kit for short bowel syndrome. The Part D plan denied coverage because medical necessity was not established. 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Gattex to treat your short bowel syndrome. The Medicare approved compendia do support the use of this drug for your condition.The plan requires for an adult patient to be dependent on parenteral support for at least 12 months with a decrease of parenteral support from baseline while on therapy with the requested medication 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 Gattex.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ascomp-Codeine 30 milligram-50 milligram-325 milligram-40 milligram capsules prescribed for chronic paroxysmal hemicrania. 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 Ascomp-Codeine for chronic paroxysmal hemicrania. 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: Favorable

You requested Cinacalcet HCl 30 milligram tablets prescribed daily for secondary hyperparathyroidism. 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 Cinacalcet HCl for secondary hyperparathyroidism in a patient with chronic kidney disease who has received a renal transplant. The medical records support hyperparathyroidism that has persisted after the renal transplant. The Medicare approved compendia do support the use of this drug for your condition. As the drug was prescribed for a medically accepted indication, coverage can be allowed.A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

You requested Adacel TDAP vaccine and administration fee. You are requesting reimbursement for the vaccination and its administration fee. We received an auto-forwarded request from the plan to reconsider the appeal.We received a 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 you received the Adacel TDAP vaccine from your physician on November 18, 2020. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. According to your plan's Evidence of Coverage, if an enrollee pays 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 plans formulary shows the drug is covered as a Tier 6 drug. The documentation includes a physicians billing statement indicating you paid for the vaccine and its administration fee in full. We determined that the plan is required to reimburse you for their share of the cost for the Adacel TDAP vaccine and administration fee.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tetracaine hydrochloride 0.5% solution prescribed as directed for the enrollees condition. 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 a supporting statement and medical records showing the medical necessity of Tetracaine hydrochloride. However, we did not receive the documentation requested.The documentation does not show why the enrollee has been prescribed Tetracaine hydrochloride. 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 Tetracaine hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Belbuca 300 microgram buccal film to treat rheumatoid arthritis. 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.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 medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. 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. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch to treat radiculopathy and chronic pain, including back pain. 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. Enrollee is using opioids on a chronic basis.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 20 milligrams. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Xarelto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. 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 for the Xarelto.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate 10 milligram tablet prescribed as directed for post-traumatic stress disorder. The Part D plan denied the request because it does not meet the criteria of 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 record shows you were prescribed Methylphenidate to treat your condition. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Methylphenidate because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Imipramine 10 milligram tablet to treat irritable bowel syndrome with diarrhea. The case was auto-forwarded by the plan. 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 documentation provided addressed the plans coverage criteria, and those criteria were not satisfied. 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 Vascepa 1 gram capsule to treat hypertriglyceridemia. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.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 Butablbital-Acetaminophen-Caffeine 50-325-40 milligram capsule to treat your condition. 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.We asked the 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 drugs on the plan's formulary would not work for you and why the plans quantity limit restriction was ineffective to treat your condition. However, we did not receive the documentation.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate 500 milligram tablets prescribed twice daily for autoimmune inflammatory myopathy. 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. Your medical records show your doctor prescribed Mycophenolate to treat your autoimmune inflammatory myopathy. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and  determined that the plan is not required to cover the Mycophenolate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Amitiza 24 microgram capsules prescribed daily for constipation related to Parkinsons disease. 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 Amitiza for constipation related to Parkinsons disease.In review of the Medicare approved compendia, constipation related to Parkinsons disease is not a medically accepted indication for Amitiza. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Amitiza at issue.