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

At issue is Braftovi to treat papillary thyroid 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mektovi to treat papillary thyroid 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 100 milligram prescribed to treat erectile dysfunction.  The Part D plan denied the request because this drug is excluded from Part D coverage.  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 including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed to treat erectile dysfunction are excluded from coverage under Medicare Part D. Therefore, the plan is not required to cover Sildenafil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle Libre 14 day Sensor prescribed for glucose monitoring. The Part D plan denied your request because this drug does not meet the definition of a Part D drug. 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 determined that the plan is not required to Freestyle Libre 14 day Sensor because Medicare law does not allow certain drugs or classes of drug to be covered under your Part D pharmacy benefit. Medicare rules state that the definition of a Part D drug includes medical supplies directly associated with the injection of insulin. 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. Therefore, the Freestyle Libre 14 day Sensor is excluded from coverage under the Part D benefit. Although, this drug is not covered under Part D, it may be covered under 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

You requested Cyclosporine Modified 25 milligrams prescribed daily for myelodysplastic syndrome. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Cyclosporine Modified to treat your myelodysplastic 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 Cyclosporine Modified.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 25 milligram tablets extended-release prescribed daily for overactive bladder. The Part D plan denied your 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. Myrbetriq is a brand drug on Tier 3 of the plans formulary. The medical records show Myrbetriq was prescribed to treat your overactive bladder. The physician progress note shows you tried Oxybutynin and experienced side effects of severe dry mouth due to vocal cord issues. However, Oxybutynin is a generic 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 coverage for Lidocaine Adhesive patch 5 percent prescribed daily for primary osteoarthritis of the right and left shoulders. 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 Lidocaine Adhesive patch for primary osteoarthritis of the right and left shoulders.In review of the Medicare approved compendia, primary osteoarthritis of the right and left shoulders is not a medically accepted indication for Lidocaine Adhesive patch. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Lidocaine Adhesive patch at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis Droperette 0.05 percent eye drops. No diagnosis was provided at determination or redetermination. 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 enrollee does not satisfy the plan's coverage criteria. The prescriber has provided information that does not satisfy the plans coverage criteria. No medical records were provided to confirm a diagnosis.  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 Tretinoin 0.05% cream prescribed for the enrollees condition. The Part D plan denied your request because drugs used for cosmetic reasons do not meet the definition of Part D 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 determined that the plan is not required to cover Tretinoin because it was used for cosmetic reasons. Drugs prescribed for cosmetic purposes or hair growth 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

You requested tacrolimus, 1-milligram capsule prescribed two capsules twice daily following a kidney transplant. 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 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 underwent a kidney transplant on June 27, 2017. Your physician prescribed tacrolimus as an anti-rejection drug. Medicare records support you enrolled in Part A and Part B Medicare beginning May 1, 2003, to present. The Medicare Part D Prescription Drug benefit does not cover drugs that are prescribed following a transplant while you are enrolled in Medicare Part B. We determined that the plan is not required to cover tacrolimus. Medicare Part B is responsible for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hizentra 2 grams/10 milliliters vial per 30 days prescribed for use with an infusion pump for the treatment of selective deficiency of immunoglobulin. 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 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 Hizentra is being administered to the enrollee via external infusion pump that is used in the home. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment, if the equipment used in the patients home. Payment may be made for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Therefore, coverage under Part D is excluded for any drug for which payment would be available under Part B. No additional documentation was requested from the prescriber. We determined that the Medicare Part D plan is not required to cover Hizentra. The Medicare policy supports the enrollees diagnosis is eligible for coverage under Medicare Part B. Therefore, Hizentra is eligible for Medicare Part B coverage. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rosuvastatin calcium 20 milligram tablets prescribed daily for hyperlipidemia. The Part D plan denied your request for a tiering exception because the documentation did not show that all generic drugs on lower tiers had been tried or considered for the treatment of hyperlipidemia. 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. Rosuvastatin calcium is a generic drug on Tier 3 of the plans formulary. The doctor submitted a supporting statement. The statement said the enrollee could not tolerate Atorvastatin due to myopathy. The doctor also said the enrollee could not tolerate Pravastatin and Simvastatin due to body aches and nausea. However, the plans formulary includes other medications, which are the same class as Rosuvastatin calcium, on Tiers 1 and 2. The doctor did not address why all alternate medications would not work for the enrollee. All generic drugs on lower tiers have not been tried. 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/milliliter autoinjector pen . The Part D plan denied your request because the drug you requested is not included on your plans formulary. We received an expedited 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 that your doctor prescribed Repatha SureClick to treat your heart disease. The Medicare approved compendium support the use of this drug to treat your condition. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Memantine Hydrochloride 10 milligrams prescribed as directed for Alzheimer's disease. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Memantine Hydrochloride 10 milligrams to treat your Alzheimer's disease. 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 Memantine Hydrochloride 10 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Memantine Hydrochloride 5 milligrams prescribed as directed for Alzheimer's disease. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Memantine Hydrochloride 5 milligrams to treat your Alzheimer's disease. 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 Memantine Hydrochloride 5 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyanocobalamin 1000 micrograms/milliliter prescribed daily for dementia and vitamin B-12 deficiency. The Part D plan denied your request because the requested drug is a prescription vitamin. 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 systems and reviewed the enrollment data available. We determined that the plan is not required to cover Cyanocobalamin 1000 micrograms/milliliter because it is a prescription vitamin and mineral product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations 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 Chlorzoxazone 500 milligram tablets prescribed 30 tablets for 30 days for severe low back pain. 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. We also researched Medicare regulations and the plans enrollment data available. The medical records show the physician had prescribed Chlorzoxazone to treat your back pain. Medicares approved compendium supports the use of the requested drug for your condition.However, the records do not show why you cannot take other drugs on your plans formulary for your condition. The plans formulary has lower cost drugs that have not been tried. Specifically, Carisoprodol, Cyclobenzaprine, and Tizanidine are included in the plans formulary. There must be indication that the enrollee tried the formulary alternatives before approving a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Chlorzoxozone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Deplin-algal oil 15-90.314 capsule prescribed daily for methylene tetrahydrofolate reductase gene mutation. The Part D plan denied your request because the drug is excluded from Part D coverage. We received a reconsideration request.We performed and 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 determined that the plan is not required to cover Deplin-algal oil because vitamins and minerals are excluded from coverage. The enrollees plan does not offer additional coverage for this drug. If drugs that are excluded are purchased, the enrollee must pay for it. This decision does not address the medical necessity 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 Jardiance, 10-milligram tablet prescribed once daily for prediabetes. The Part D plan denied your request because your diagnosis of prediabetes is not a Food and Drug Administration supported 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 Jardiance to treat your prediabetes. 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 Jardiance because you do not have a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Trospium Chloride Extended Release, 60 milligrams prescribed one daily for urinary incontinence. You asked the Part D plan to provide a cost-sharing tiering exception. The plan denied the appeal because this drug is not listed on your formulary plan (non-formulary); however, your plan approved this drug as a formulary exception. Medicare says you cannot get a tiering exception (co-pay reduction) for a non-formulary drug approved as a 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. Your medical records show Trospium Chloride Extended Release is being prescribed for urinary incontinence. This drug is not listed in your formulary plan. However, your plan approved the drug for your use as a formulary exception. Medicare does not allow a cost-sharing exception for drugs approved as a formulary exception. Therefore, the requested drug is not eligible for a cost-sharing tiering exception (co-pay reduction).A physician reviewed your appeal and determined that the plan is not required to cover Trospium Chloride Extended Release because Medicare does not allow a cost-sharing exception for drugs approved as a formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brilinta 90 milligrams prescribed twice daily for myocardial infarction. The Part D plan denied your request for a tiering exception. 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. Brilinta 90 milligrams 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 cover Brilinta 90 milligrams because there are no brand drugs of the same type on the lower cost sharing tiers.