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

At issue is Eliquis 5 milligrams, 70 tablets for 28 days. The Part D Plan denied your request for a tiering exception because the drug was listed on the plans formulary at the lowest possible cost tier. We received an expedited 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. Eliquis is prescribed for anticoagulation in an enrollee with pulmonary embolus.  Eliquis  is a brand name drug on Tier 2 of the plans formulary.  There are no brand name 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 the Eliquis at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil citrate 20 milligram tablets prescribed as directed for hypertension. 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. We also researched Medicare systems and reviewed the enrollment data available. The documentation shows your doctor initially requested Sildenafil at Redetermination to treat  esophageal spasms.  At Reconsideration the prescriber changed the diagnosis to hypertension.  The Medicare approved compendia do not contain any citations to support the use of the requested drug to treat the provided diagnoses. A physician reviewed your appeal and determined that the plan is not required to cover sildenafil citrate. The drug at issue has not been prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitriol 0.25 micrograms prescribed three times daily for the diagnosis of hypocalcemia with end-stage renal disease on hemodialysis. The Part D plan denied the request because medication related to End-Stage Renal Disease is not covered under Part D but may be eligible under Medicare Part A or Part B. 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 the enrollee has End-Stage Renal Disease and requires hemodialysis. The physicians office note indicates the enrollee had symptomatic hypocalcemia and Calcitriol 0.25 micrograms was ordered to be taken three times a day. However, End-Stage Renal Disease treatment for enrollees on dialysis, including drugs given outside of a dialysis facility, are bundled into the end-stage prospective payment and are not covered under the Part D drug coverage benefits. Medicare systems show the enrollee was eligible for coverage under Part A and Part B as of May 1, 2008. This drug would be billable under Medicare Part B. We determined that the plan is not required to cover Calcitriol 0.25 micrograms. You may wish to submit a request for calcitriol to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligram prescribed for hyperlipidemia. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited 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. Your physician submitted a supporting statement and medical records. The medical records show the physician had prescribed Repatha to treat your hyperlipidemia. The Medicare approved compendia support 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. Specifically, Praluent is on the formulary and your physician did not indicate why you cant take this drug.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 Pradaxa 150 milligram capsules prescribed twice daily for recurrent deep vein thrombosis. The Part D plan denied your request for a tiering exception 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. 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.Pradaxa is a brand drug, which is not included on your plans formulary. 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 Pradaxa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 3% Gel, 100 grams per 30 days for plantar fascial fibromatosis. The Part D plan denied your request because the drug was ordered for a non-medically accepted indication. We received an expedited 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. Your medical records show your doctor prescribed Diclofenac Sodium 3% Gel to treat your plantar fascial fibromatosis. 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 the Diclofenac Sodium 3% Gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Soliqua 100/33 20 units prescribed daily for type 2 diabetes mellitus with unspecified complications. The Part D plan denied your request for a tiering exception. We received an expedited 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. Soliqua 100/33 20 units is a brand drug on Tier 3 of the plans formulary. The prescriber statement shows you were prescribed Soliqua 100/33 20 units for type 2 diabetes mellitus with unspecified complications. 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 Soliqua 100/33 20 units.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Erleada 60 milligrams prescribed daily for metastatic castrate-resistant prostate cancer. The Part D plan denied your request because the drug was prescribed for a non-medically accepted indication. We received an expedited 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.Your medical records show your doctor prescribed Erleada to treat your metastatic castrate-resistant prostate cancer. However, all the Medicare required compendia were reviewed and no citations were found. Therefore the references do not support the use of this drug for your condition. In addition, your prescriber did not include any medical articles from a Medicare approved journal to support use of this drug.A physician reviewed your appeal and determined that the plan is not required to cover Erleada.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Praluent 75 milligrams per milliters, pen injector, once every two weeks, prescribed for hyperlidemia. The Part D Plan denied the request for a cost sharing/tiering exception. We received your request to reconsider the appeal.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.Praluent is a brand generic drug on Tier 4 of the plans formulary. There are no other brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.The records show Praluent is prescribed for hyperlipidemia. A Medicare approved compendium, supports the use of the requested drug for your condition. Praluent is a brand name drug on Tier 4 of your plan's formulary. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover or allow payment under your Medicare Part D benefit for Praluent 75 milligram, pen injector.
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 an expedited 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.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

You requested Fanapt 2 milligrams, 90 tablets every 30 days for the treatment of the following conditions: autism spectrum disorder, 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) code F84.0; unspecified disruptive, impulse control and conduct disorder, ICD-10 code F91.9; and severe intellectual developmental disorder, ICD-10 code F72. The Part D plan denied your request because the enrollee did not have a medically accepted indication. We received an expedited 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.The medical records show that Fanapt was prescribed to treat autism spectrum disorder; unspecified disruptive, impulse control and conduct disorder; and severe intellectual developmental disorder. The Medicare approved compendia, American Hospital Formulary Service Drug Information and DrugDex, do not support the use of this drug for these conditions. Since the drug is being prescribed to treat non-medically accepted indications, the request to exceed the quantity limits allowed cannot be taken into consideration.A physician reviewed your appeal and determined that the plan is not required to the Fanapt.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuzyra 300 milligrams prescribed daily for a mycobacterial infection. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received an expedited auto-forwarded reconsideration request from the plan. 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.Your medical records show your doctor prescribed Nuzyra 300 milligrams daily to treat your mycobacterial infection. However, the Medicare approved compendia, DrugDex and American Hospital Formulary Service Drug Information, 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 Nuzyra 300 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Zarxio 480 micrograms prescribed 4.0 every five days for neutropenia due to cytomegalovirus infection and myfortic. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 you were prescribed Zarxio for neutropenia due to cytomegalovirus infection and myfortic. In review of the Medicare approved compendium, DrugDex and American Hospital Formulary Service, neutropenia due to cytomegalovirus infection and myfortic is not a medically accepted indication for Zarzio. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Zarzio at issue. In conclusion, our decision is unfavorable.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fanapt 2 milligrams prescribed three times a day for a diagnosis of unspecified disruptive impulse control and conduct disorder. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 you were prescribed Fanapt 2 milligrams prescribed three times a day for a diagnosis of unspecified disruptive impulse control and conduct disorder.In review of the Medicare approved compendium, DrugDex and American Hospital Formulary Service, of unspecified disruptive impulse control and conduct disorder. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Fanapt at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ongentys 50 milligram capsule prescribed daily for Parkinsons disease. The Part D plan denied your request for a non-formulary drug. The plan indicated your prescriber did not confirm that you have tried the formulary alternatives that treat your condition. 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 Ongentys was prescribed to treat Parkinsons disease. A prescriber statement indicates that Neupro, Mirapex ER, Azilect, Sinemet, gabapentin, pramipexole, and mirtazapine were tried. It was noted that these drugs did not improve your condition. However, the plans formulary includes other drugs that could be used to treat the same condition. The medical records do not show all alternative drugs on the plans formulary have been tried or why the enrollee cannot take them. A physician reviewed your appeal and determined that the plan is not required to grant a non-formulary exception for the Ongentys.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 Xpovio 80 milligrams prescribed weekly as a therapeutic pack of 16 tablets per 28 days for the diagnosis of glioblastoma. The Part D plan denied your request because the drug was not ordered for a medically accepted indication. We received an expedited 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 the Medicare approved compendia.Your medical records show your doctor prescribed Xpovio to treat your glioblastoma. However, the Medicare approved compendia do not support a medically accepted indication for the use of this drug for your condition. There were no articles from Medicare approved literature submitted to support a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Xpovia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xyrem 500 milligrams per milliliter solution prescribed twice daily for insomnia. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received an expedited 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 information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Xyrem 500 milligrams per milliliter solution twice daily to treat your insomnia. 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 Xyrem 500 milligrams per milliliter solution because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Buprenorphine Hydrochloride 2 micrograms sublingual prescribed three times a day for pain in the back and knees. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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. We also researched Medicare systems and reviewed the enrollment data available.The record shows you were prescribed Buprenorphine Hydrochloride sublingual for pain in the back and knees. In review of the Medicare approved compendium, pain in the back and knees is not a medically accepted indication for sublingual Buprenorphine Hydrochloride. A physician reviewed your appeal and determined that the plan is not required to cover the Buprenorphine Hydrochloride sublingual at issue because it does not meet the definition of a Part D drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dexmethylphenidate HCL 5 milligrams prescribed once daily for hypersomnia in an enrollee with chronic Lyme disease. 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 records show your doctor prescribed Dexmethylphenidate HCL to treat your idiopathic hypersomnia. 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 Dexmethylphenidate HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Envarsus XR, a 1 milligram tablet prescribed once 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical record shows that you underwent a kidney transplant on October 29, 2019. Your physician prescribed Envarsus XR as an anti-rejection drug. Medicare records support you were enrolled in Part A and Part B Medicare beginning November 1, 2015, to present. The transplant was performed in a Medicare approved facility when you were entitled to Medicare Part A. 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 Envarsus XR. Medicare Part B is responsible for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gamunex-C Solution 40 grams per 400 milliliters prescribed daily for acute transverse myelitis. The Part D plan denied your request because the medically accepted indication criteria was not met. We received an expedited reconsideration request from the plan. 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. The medical records show Gamunex-C Solution was ordered to treat recurrent transverse myelitis. However, the Medicare approved compendia do not support the use of this drug for this condition. The medical records submitted do not show the enrollee has a medically accepted indication for the drug.A physician reviewed your appeal and determined that the plan is not required to cover Gamunex-C Solution 40 grams per 400 milliliters.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta 50 milligram tablet prescribed every four to six hours, as need for neuropathy. The Part D plan denied your request for a non-formulary drug. The plan indicated you did not have a medically accepted indication for this drug. 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 Nucynta was prescribed to treat neuropathy.  A prescriber statement also indicates for moderate acute pain and diabetic neuropathy. The Medicare approved compendium does support the use of this specific drug for your condition.   Nucynta 50 milligram tablet is not on the plan's formulary.  The prescriber has not addressed all of the plan's formulary alternatives to treat the enrollee's condition.  A physician reviewed your appeal and determined that the plan is not required to cover Nucynta. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.