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

At issue is Emgality, 120 milligrams per 1 milliliter, one injection pen per 30 days prescribed for migraine. 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 auto-forwarded reconsideration request from the plan.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 requested and submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. A physician reviewed your appeal and determined that the plan is not required to cover the Emgality. The submitted documentation shows that the drug was prescribed to treat your migraine headaches. No medical records were received with this reconsideration. The Medicare approved compendia do support the use of the requested drug for this condition. However, the submitted documentation does not include your medical records from your doctor to validate that you have satisfied the plan's prior authorization requirements for coverage of the Emgality.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 1 percent gel 1 gram as needed to treat osteoarthritis of the lumbar spine. 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 record shows you were prescribed Diclofenac Sodium 1 percent gel for osteoarthritis of the lumbar spine. At reconsideration diagnoses of pain in shoulder and hands, osteoarthritis and trochanteric bursitis were given. No medical records were provided by the prescriber to support this diagnosis. 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.In addition, the documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, would likely cause harm or not be as effective as the requested drug.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Epclusa 400mg/100mg tablet to treat hepatitis C.  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. 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 requested drug is not eligible for Part D coverage
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clobazam 10 milligram tablets 75/30, prescribed for intractable, symptomatic epilepsy with complex partial seizures without status epilepticus. The Part D plan denied your 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Clobazam 10 milligram tablets to treat your intractable, symptomatic epilepsy with complex partial seizures without status epilepticus. Seizures have been ongoing for multiple decades and also treated with Vimpat and Lamictal. The Medicare approved compendia do support the use of this drug as a medically accepted indication for your condition. In Micromedex, a Medicare approved compendia, a positive citation was identified. It states  Clobazam in doses of 20 mg daily initially (increasing to 30 or 40 mg daily if required) was reported effective as add-on therapy in drug-resistant epilepsy in an uncontrolled study involving 30 patients. All patients had epilepsy of at least 10 years' duration, with an average of 7 seizures monthly during the 3 months prior to initiation of clobazam therapy; 18 patients had focal epilepsy (primarily temporal lobe type with partial complex seizures) and 12 patients had primary generalized seizures. At an average of 28 months of follow-up, seizure frequency was reduced by greater than 70% in 13 patients (43%) and by 50 to 75% in 7 patients (24%). Side effects were minimal during therapy. Medication is being prescribed by a neurologist.However, the plan has a quantity limit restriction of 60 tablets/30 days. This  issue has not been addressed by the prescriber in the provided records, and other strengths of the drug have also not been addressed. The plan's coverage criteria have not been satisfied. Therefore, the drug cannot be considered for payment under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Ezetimibe 10 milligram tablets to treat mixed hyperlipidemia.   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.Ezetimibe 10 milligram tablet is a generic drug on Tier 3 of the plans formulary. There are no generic 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. Our Physician Reviewer's opinion is that tiering exception criteria are not met.  .
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 100 milligram capsules to treat osteoarthritis of the hips. 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 is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate HCL 20 milligrams prescribed twice daily for multiple sclerosis related fatigue. The Part D plan denied your 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Methylphenidate HCL 20 milligrams twice daily to treat your multiple sclerosis related fatigue. The use of the requested drug to treat the provided diagnosis is an off-label use. 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 Methylphenidate HCL 20 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Daliresp 500mcg tablet to treat chronic obstructive pulmonary disease.   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.Daliresp 500mcg tablet is a brand drug on tier 3 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. Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methlyphenidate HCL 5 milligram tablet to treat hypersomnia and obstructive sleep apnea. 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 is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Mycophenolate 500 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.Mycophenolate 500 milligram tablet 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

At issue is Eucrisa 2% ointment prescribed for eczema. The Part D plan denied your request for an off-formulary drug because the documentation did not support that the drug was 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 prescriber submitted a supporting statement at reconsideration. This prescribers statement shows the enrollee was prescribed Eucrisa to treat eczema. The Medicare approved compendia do support the use of Eucrisa for atopic dermatitis (eczema). However, the prescriber statement submitted to the plan lists different diagnoses and medical records were not submitted to corroborate the diagnoses reported. There is insufficient documentation to establish that the drug was prescribed for a medically accepted indication.Additionally, the prescriber statement shows the enrollee has contraindications to two other drugs available on the plans formulary. However, the documentation does not show why the enrollee is unable to use the other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Eucrisa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Radicava 30 milligrams/100 milliliter intravenous solution to treat Amyotrophic lateral sclerosis. 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.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 requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxymorphone hydrochloride ER 15 miiligram to treat chronic pain. The case was auto-forwarded by the plan.  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 plan limits the amount of opiates to a morphine equivalent of 200 milligrams per day. The enrollee exceeds the morphine equivalent of 200 milligrams per day with Oxymorphone Hydrochloride 15 milligram ER twice daily and Oxymorphone Hydrochloride IR 10 milligrams every 6 hours. Therefore, the plans quantity limits are exceeded. 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 Xeljanz 5 milligram tablets prescribed for lichen planopilaris. 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 the drug for lichen planopilaris. 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 Savella 50 milligrams prescribed twice daily. The Part D plan denied the request for a tiering exception. 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.This drug is being provided by your 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.A physician reviewed your appeal and determined that the plan is not required to reimburse payment made for Savella.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolic Acid Delayed Release 360 milligrams prescribed daily for your immunosuppression therapy for a renal transplant. The Part D Plan denied the request for coverage. 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.The record shows that you received a kidney transplant on February 11, 2008. According to Medicare enrollment records, you were entitled to Medicare Part A coverage on November 1, 2001. Medicare law excludes coverage for any drug under the Part D program for which payment would be available under Parts A or B. Coverage is available under Medicare Part B for prescription drugs used in immunosuppressive therapy for an enrollee that was covered under Medicare Part A at the time of a transplant. You were covered under Medicare Part A at the time of your transplant. Therefore, coverage is available under 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 Prednisone 5 milligrams prescribed daily for your immunosuppression therapy for a renal transplant. The Part D Plan denied the request for coverage. 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.The record shows that you received a kidney transplant on February 11, 2008. According to Medicare enrollment records, you were entitled to Medicare Part A coverage on November 1, 2001. Medicare law excludes coverage for any drug under the Part D program for which payment would be available under Parts A or B. Coverage is available under Medicare Part B for prescription drugs used in immunosuppressive therapy for an enrollee that was covered under Medicare Part A at the time of a transplant. You were covered under Medicare Part A at the time of your transplant. Therefore, coverage is available under 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 Tacrolimus 1 milligram prescribed daily for your immunosuppression therapy for a renal transplant. The Part D Plan denied the request for coverage. 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.The record shows that you received a kidney transplant on February 11, 2008. According to Medicare enrollment records, you were entitled to Medicare Part A coverage on November 1, 2001. Medicare law excludes coverage for any drug under the Part D program for which payment would be available under Parts A or B. Coverage is available under Medicare Part B for prescription drugs used in immunosuppressive therapy for an enrollee that was covered under Medicare Part A at the time of a transplant. You were covered under Medicare Part A at the time of your transplant. Therefore, coverage is available under Medicare Part B.The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Afinitor 10 milligram tablets to treat metastatic rectal cancer. 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 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 medical record shows the requested drug has been prescribed to treat your condition. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of your condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Shingrix to prevent shingles.  The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from 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 requested drug is on the formulary and does not have step therapy or prior authorization criteria.  Therefore, the requested drug is eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix vaccine 0.5 milliliters for the prevention of herpes zoster (shingles). 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. We also researched Medicare systems and reviewed the enrollment data available. Shingrix vaccine is a biologic drug on Tier 3 of the plans formulary. There are no biologic 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. Our Physician Reviewers opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Jardiance 10 milligram tablet 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.Jardiance 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.Our Physician Reviewer's opinion is that tiering exception criteria are not met.