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

At issue is Mycophenolate Mofetil 500 milligram tablet prescribed daily for connective tissue related interstitial lung disease. The Part D plan denied the request.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 records submitted at the reconsideration level.At reconsideration, additional medical records dated May 13, 2021 with new laboratory testing,  show the doctor prescribed Mycophenolate Mofetil to treat the enrollees scleroderma related interstitial lung disease. The following citation was referenced in American Hospital Formulary Service Drug Information (AHFS-DI), a Medicare approved compendium, and supports the use of this drug for your condition: 'Mycophenolate Mofetil has been used in the management of systemic sclerosis (often called scleroderma) and cardiopulmonary involvement, particularly interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH), accounts for most of the increased mortality in patients with this condition.' Micromedex has similar positive citations.  The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The Medicare policy supports the enrollees diagnosis is not eligible for coverage under Medicare Part B. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested compounded Diltiazem 2% cream prescribed for anal fissures. 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.This drug is a compounded drug. Therefore, we reviewed each ingredient individually.  The ingredients of the requested drug are: Diltiazem powder, Propylene Glycol, and Dermabase cream. Propylene Glycol and Dermabase cream are non-prescription or over-the-counter (OTC) drugs. Medicare Part D does not cover non-prescription drugs. Therefore, the Propylene Glycol and Dermabase cream ingredients are not eligible for Part D coverage. Diltiazem is a bulk powder. Bulk powders (i.e., Active Pharmaceutical Ingredients for compounding) do not satisfy the definition of a Part D drug and are not covered by Part D. Therefore, none of the ingredients of the requested drug are Part D drugs. Compounded medications that do not contain at least one ingredient that meets the definition of a Part D drug are excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested the off-formulary Diphenoxylate-Atropine 2.5-0.25 milligram tablet prescribed daily for Crohns disease and short bowel syndrome. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Diphenoxylate-Atropine to treat your Crohns disease and short bowel syndrome. 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 Diphenoxylate-Atropine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Toujeo Max Solostar 300 unit/milliliter injector prescribed 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.Toujeo is a brand biologic on Tier 3 of the plans formulary. There are no brand biologics of the same type on the lower cost sharing tiers. Therefore, this biologic 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 request for coverage of Gralise 600 milligram tablets. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Gralise has been prescribed for the treatment of trigeminal neuralgia. However, 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 drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the Gralise tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Vimpat 200 milligram tablets prescribed 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.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

At issue is a tiering exception request for Nayzilam 5 milligram nasal spray prescribed 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.Nayzilam 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 Repatha Sureclick 140 milligram per milliliter solution auto-injector prescribed for atherosclerosis of aorta and hyperlipidemia, unspecified. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 microgram inhalation prescribed daily for chronic obstructive pulmonary disease. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your medical records show your doctor prescribed Anoro Ellipta to treat your chronic obstructive pulmonary disease. Your plan has prior authorization requirements for this drug that must be met 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 Anoro Ellipta. There is no evidence that you have tried or have a contraindication/intolerance to Bevespi Aerosphere. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rifaximin bulk powder prescribed for propionic acidemia. 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.We determined that the plan is not required to cover Rifaximin powder. This drug product is to be compounded using the bulk powder form of the drug. A Medicare Part D drug is one approved by the Food & Drug Administration. The bulk powder form of this drug is not approved by the Food & Drug Administration, and is therefore not covered.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sodium Benzoate powder prescribed for propionic acidemia. 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.We determined that the plan is not required to cover Sodium Benzoate powder because it is an over-the-counter drug that does not require a prescription. Nonprescription or over-the-counter drugs are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Levocarnitine 1000 milligram per 10 milliliter solution prescribed for propionic acidemia. The Part D plan denied the 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 records submitted at the reconsideration level. Levocarnitine does not meet the definition of a Part D drug, as this drug is available over the counter without a prescription. Nonprescription drugs are excluded from the Part D benefit. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cimetidine tablets prescribed for other sexual dysfunction. 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.We determined that the plan is not required to cover Cimetidine because it was prescribed for sexual dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Desvenlafaxine Succinate Extended Release 25-milligram tablet. At initial determination and redetermination the diagnosis of schizoaffective disorder, bipolar type was given. 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.At reconsideration a diagnosis of major depressive disorder was 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.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 a request for coverage of a 90-day supply of Gralise ER 600 milligram tablets. The Part D plan denied the request for coverage because specialty drugs, such as non-formulary drugs, are limited to a recurring 30-day supply. Additionally, the medication was being used 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 indicates that Gralise ER has been prescribed for the treatment of trigeminal neuralgia. However, 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 drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage under Medicare Part D, the plans quantity limit criteria are not relevant to this review. A physician reviewed the appeal and determined that the plan is not required to cover the Gralise ER tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 20-10 milligram capsules prescribed for pseudobulbar affect. 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 did not contain a supporting statement or medical records from your doctor. A request for a supporting statement and medical records was sent. A supporting statement was returned that indicates you have a diagnosis of pseudobulbar affect; however, there were no medical records submitted to corroborate you have a medically accepted indication. As it cannot be determined that the drug was 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 Nurtec ODT 75millagram tablet prescribed for migraine headaches. The Part D plan denied your request. The requested drug is not on the plans formulary.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Nurtec ODT.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested the Sildenafil Citrate 20 milligram tablet prescribed daily for Raynauds syndrome without gangrene. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Sildenafil Citrate to treat your Raynauds syndrome without gangrene. 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 Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Fentanyl 72-hour patches at a dose of 25 micrograms per hour prescribed for malignant neoplasm of anterior two-thirds of tongue. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation does not satisfy the plans coverage criteria for this medication. 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 50 milligram tablets prescribed as directed for hypersomnia due to myotonic dystrophy. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Armodafinil to treat your hypersomnia due to myotonic dystrophy. However, the Medicare approved compendia do not support the use of this drug, as prescribed, for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tolterodine Tartrate 4 milligram extended release tablet to treat an unknown diagnosis. The Part D plan denied the 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 records submitted at the reconsideration level. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  In addition, the drug requested has step therapy requirements. The prescriber has not indicated that all alternatives required by the plan have been tried and failed, or why the plans required step therapy drugs would likely not be as effective as the requested drug. 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested PFD-2 powder prescribed for propionic acidemia. 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.We determined that the plan is not required to cover PFD-2 powder because it is an over-the-counter product. Nonprescription or over-the-counter drugs are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fasenra 30 milligram per milliliter pre-filled syringe prescribed every 8 weeks for severe persistent 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Fasenra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle libre 14 day reader device prescribed for the diagnosis of diabetes mellitus. 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 determined that the plan is not required to Freestyle libre 14 day sensor because it is not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acyclovir 5% Cream prescribed for herpesviral vesicular dermatitis with chronic skin lesions. 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. Your prescriber indicates that Acyclovir 5% Cream is prescribed for herpesviral infection. The medical records submitted show that you have herpes vesicular dermatitis. Medicare approved compendia does not support this drug, as prescribed,  for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Acyclovir 5% Cream.