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

At issue is Cialis 5 milligram tablet to treat erectile dysfunction. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine-Dextroamphetamine 30 milligram tablets prescribed daily for major depressive disorder recurrent without psych features. 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 prescriber statement shows Amphetamine-Dextroamphetamine was prescribed to treat a long psychiatric history of treatment resistant depression. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Amphetamine-Dextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone Propianate/Versabase Cream compound prescribed for abnormal level of hormones in specimens from other organs, systems and tissues. The Part D plan denied your request because the drug at issue was not Food and Drug Administration approved. We received an expedited auto-forwarded reconsideration request from the coverage level. 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 your physician prescribed the compound at issue for your diagnosis of abnormal level of hormones in specimens from other organs, systems and tissues. The compound at issue does not contain components that are Food and Drug Administration approved. Therefore, the compound cannot be considered a Part D benefit.We determined that the plan is not required to cover the compound.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Coreg CR 20 milligram tablets prescribed daily for heart failure. The Part D plan denied your request for a tiering exception because the drug at issue was covered as a formulary exception and was not eligible 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.Coreg CR is a non-formulary drug. Non-formulary drugs are covered by the plan on Tier 4 and are 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 coverage for Alosetron HCL 1 milligram prescribed daily for irritable bowel syndrome, severe diarrhea-predominant. 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 Alosetron for irritable bowel syndrome, severe diarrhea-predominant. In review of the Medicare approved compendia, irritable bowel syndrome, severe diarrhea-predominant is a medically accepted indication for Alosetron. However, it is only approved for females with irritable bowel syndrome, severe diarrhea-predominant. The records submitted do not indicate that the enrollee is a female.  Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Alosetron at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100 micrograms/62.5 micrograms/25 micrograms inhaler 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 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.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

At issue is Dupixent 300 milligram/2 milliliter injections prescribed for atopic dermatitis. The Part D plan denied your request for a tiering exception because the drug you requested is not included on the plans formulary. 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 was approved on April 15, 2020, through July 14, 2021, for coverage of a non-formulary drug. 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 grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vimpat 200 milligram tablets 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 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.Vimpat 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

You requested Diclofenac Sodium 3% Gel prescribed for osteoarthritis and radiculopathy of the sacral and sacrococcygeal region. 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 the drug for osteoarthritis and radiculopathy of the sacral and sacrococcygeal region. 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

You requested Mycophenolate Mofetil 500 milligram tablets prescribed twice daily following a lung transplant. The Part D plan denied your request because the drug was prescribed for 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.Your medical records show your doctor prescribed Mycophenolate Mofetil following your lung transplant for immunosuppressive therapy. 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 2.5 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.Eliquis 2.5 mg 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.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Repatha Sureclick 140 milligrams/milliliter prescribed for the enrollees coronary artery disease. 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 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 records submitted at the reconsideration level. The enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee was prescribed Repatha to reduce the risk of myocardial infarction, stroke, and unstable angina due to coronary artery disease. In addition, the medical records support the enrollee has tried and has an intolerance to several different statins.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets for hepatic failure. The Part D plan denied your request for a quantity limit exception request. We received a 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 information submitted at the reconsideration level.The documentation indicates your doctor prescribed Xifaxan to treat your hepatic failure. The drug at issue was approved as a specialty drug, which is only approved for a 30 day supply. An exception to the quantity limit criteria was not met.Therefore, the plan is not required to cover Xifaxan for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gleostine 100 milligram capsules prescribed for glioblastoma. The Part D plan denied your request because the drug was excluded from coverage under Medicare Part D because it is a biologic drug, and its manufacturer has not signed the Medicare Coverage Gap Discount Agreement. 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 Gleostine is excluded from coverage under Medicare Part D because it is a brand drug and its manufacturer has not signed the Medicare Coverage Gap Discount Agreement. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare & Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. The manufacturer, NextSource biotechnology, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Gleostine. 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 Aripiprazole 2 milligram tablets twice per day for major depressive disorder. The Part D plan denied your request for a tiering exception because the drug is covered at the cost-sharing Tier listed in the 2021 Drug Guide and the prescriber did not explain why the alternative drugs in a lower Tier would not work as well. 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 prescriber indicates the Olanzapine is approved for depression only with fluoxetine, Quetiapine extended release was not metabolically indicated, and Quetiapine immediate release and Risperidone were not indicated for major depressive disorder. The other drugs listed were not on the formulary and are not addressed here.  Quetiapine immediate release and Risperidone are generic brands on a lower Tier in the plans formulary and are medically indicated to treat major depressive disorder. The prescriber did not address why these other medications were not tried or why he feels they might result in an adverse effect. 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 Sofosbuvir/Velpatasir 400/100 milligram tablet, for the enrollees chronic hepatitis C virus. The Part D plan denied the request. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Sofosbuvir/Velpatasir 400/100 milligram tablet is not on the Plan's formulary.  Epclusa 400/100 milligram tablet is on the Plan's formulary. The prescriber has not indicated that the enrollee has tried all alternatives and why those alternatives would not work for your condition as required by the plan. 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 Repatha, 140 milligrams per milliliter solution auto-injector prescribed for carotid artery stenosis. The Part D plan denied your request because the documentation did not support an off-formulary 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. A physician reviewed your appeal and determined that the plan is not required to cover the Repatha as an off-formulary exception.Your doctor submitted a supporting statement stating that Repatha was prescribed to treat your carotid artery stenosis. The Medicare approved compendia support the use of the requested drug for your condition. However, the documentation does not address why the formulary alternatives listed in your Part D plan to treat your condition have not been tried, or are contraindicated.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sirolimus, 0.5 milligram tablets for the prevention of rejection of a liver following transplant. The Part D plan denied your request because this conditions is not a medically accepted indication for the use of this medication. 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 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 the noted condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Topamax 100 milligram tablets for the diagnoses of major depressive disorder, generalized anxiety, and severe anxiety. The Part D plan denied your request because this drug is not medically accepted for this condition. We received a 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. We also researched Medicare regulations and Medicare approved compendia. 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. The drug is not approved by the food and drug administration to treat the diagnoses submitted. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested True Metrix Glucose Test Strips prescribed for monitoring your blood glucose levels. The Part D plan denied the appeal because test strips, lancets, and needle disposal systems are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. We received an auto forwarded 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 medical record shows that you are a person with diabetes. Glucose monitoring supplies (test strips) are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Medicare Part D. As such, the True Metrix Glucose Test Strips are excluded from Part D coverage by Medicare law.We have determined that your plan is not required to cover True Metrix Glucose Test Strips. Medicare Part B/Durable Medical Equipment is responsible.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cinacalcet HCl 30 milligrams (12/28) prescribed for chronic kidney disease. 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 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 the drug for chronic kidney disease. The Medicare approved compendia do not support the use of this drug for your condition. Your doctor indicated you are not on dialysis. 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 Gammunex-C for primary immunodeficiency. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug would be eligible for coverage under Part B under Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Adacel vaccine. The Part D plan denied the request because the records did not include a valid National Drug Code number for the medication you received, which is required to process your request for reimbursement. We received a 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.The record shows you received Adacel vaccination on October 15, 2020. However, the records submitted do not include the National Drug Code number. The National Drug Code number is required to process your request for reimbursement. We determined that the plan is not required to reimburse you for the Adacel vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Visbiome Probiotic Powder, 20-milligrams prescribed one packet daily for ulcerative colitis. The Part D plan denied the appeal because the drug is excluded under the Medicare Part D benefit. There are no conditions under which this request would be approved under Medicare Part D. 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. Your record shows that your doctor prescribed Visbiome Probiotic Powder for your ulcerative colitis. Visbiome Probiotic Powder is excluded from coverage under the Medicare Part D benefit because the drug does not meet the definition of a Part D drug. This is not to say that this drug does not benefit you, just that Medicare does not allow this drug for any condition under the Medicare Part D benefit. We have determined that your plan is not required to cover Visbiome Probiotic Powder because the drug does not meet the definition of a Part D drug under Medicare law.