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

At issue is Hizentra 10 gram/50 milliliter vial prescribed for use with an infusion pump for the treatment of common variable 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. 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 DME, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. The Medicare policy supports the enrollees diagnosis is eligible for coverage under Medicare Part B. We determined that the Medicare Part D plan is not required to cover Hizentra. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sucraid 8500 units/milliliter prescribed for the enrollees sucrose-isomaltase deficency. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of sucrose-isomaltase deficiency. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.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 Uloric 40 milligram tablets for cellulitis. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates Uloric was prescribed for cellulitis. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus 1 milligram capsules to treat the enrollees condition. The Part D Plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read 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 medical records show the requested drug is being prescribed to treat the enrollees condition. The enrollees medical history includes a kidney transplant on April 12, 2009. According to Medicare, the enrollee was under Medicare Part A coverage at the time of the transplant. Based on the information provided, we have determined the requested drug is not eligible for Medicare Part D coverage, but would be covered under Part B.A physician reviewed your appeal and determined that the requested drug is not eligible for Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vraylar 1.5 milligram capsules for major depression disorder. The Part D plan denied your request for prior authorization 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 documentation shows Vraylar was prescribed to treat the enrollees major depressive disorder. However, the Medicare approved compendia do not support the use of Vraylar for this condition. Since the drug was not prescribed for a medically accepted indication, the prior authorization request cannot be granted.A physician reviewed your appeal and determined that the plan is not required to cover Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone-chlorphen extended release suspension prescribed for cough relief. The plan denied the request because Medicare excludes drugs used for the symptomatic relief of cough and cold. 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.According to Medicare rules, drugs used for the symptomatic relief of cough and cold are excluded from coverage. The record shows the Hydrocodone-chlorphen is used to relieve the enrollees coughing spells. Therefore, we determined that the plan is not required to cover the Hydrocodone-chlorphen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Kesimpta 20 milligram per 0.4 milliliter subcutaneous injection pen. The Part D plan denied your 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.  The documentation supports that Kesimpta has been prescribed to treat the enrollees multiple sclerosis. Kesimpta is not included in the plans formulary. The prescriber has not sufficiently addressed why all alternative drugs included in the plan to treat this condition have been tried and failed or would likely not be as effective as the requested drug or would likely cause adverse reactions or other harm. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Venclexta Starter Pack 10 milligram/50 milligram/100 milligrams prescribed for the enrollees chronic lymphocytic leukemia. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of chronic lymphocytic leukemia. It is noted that the enrollee had a reaction to rituximab in the past which required stopping rituximab. The enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 8 milligrams, disintegrating tablets. The Part D plan denied your request because you did not have a medically accepted indication for this drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The documentation indicates that Ondansetron is prescribed to treat intractable nausea, cyclical vomiting, in migraine. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s).A physician reviewed your appeal and determined that the plan is not required to cover Ondansetron.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 10 milligram tablet prescribed as directed to treat type 2 diabetes mellitus. The Part D plan denied your request for a tiering exception because there were no brand drugs of the same type on the lower cost sharing tiers. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Jardiance 10 milligram tablet 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.Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sodium Chloride 0.9% solution as part of a compound for urinary tract infection. The Part D plan denied your request because one or more of the drugs in the compound did not meet the definition of a Part D drug. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover the Sodium Chloride compound. The drugs that make up the compound do not meet the definition of Part D drugs. 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 Xifaxan 550 milligram tablets prescribed three times daily for microscopic colitis. The Part D plan denied your request because the provide diagnosis 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 you were prescribed Xifaxan 550 milligram tablets to treat your microscopic colitis. However, the Medicare approved compendia do not support the use of this drug for this 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 Xifaxan 550 milligram tablets because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alrex 0.2% ophthalmic solution to be given one drop each eye twice daily for primary open-angle glaucoma. The Part D plan denied the drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any records submitted at the reconsideration level.Alrex 0.2% ophthalmic solution is being requested to treat primary open-angle glaucoma. The Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover the Alrex.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tymlos 3120 microgram/1.56 milliliter injection pen prescribed for disorder of bone density and structure. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Tymlos for disorder of bone density and structure. 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 Promethazine HCL 25 milligram suppository prescribed as directed for nausea related to gastroparesis. The Part D plan denied the request stating that the provided diagnosis is a non-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 record shows you were prescribed Promethazine HCL to treat your condition. 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 the Promethazine HCL because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Acitretin 10 milligrams prescribed daily for Grover's disease. The Part D plan denied your request because the provide diagnosis 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 Acitretin to treat your Grover'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 Acitretin because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spiriva 18 micrograms handihaler prescribed for asthma. 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.Spiriva 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

You requested Reyvow 50 milligrams for migraine headaches. The Part D plan denied coverage because the plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. The medical records show the physician prescribed Reyvow for migraine headaches. Medicare approved compendia does support the use of this drug for your condition. However, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria. The prior authorization requires the enrollee to have less than 15 headache days per month. A physician reviewed your appeal and determined that the plan is not required to cover Reyvow.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gattex Kit 5 milligrams prescribed for the enrollees short bowel syndrome. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of short bowel syndrome. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% topical patches prescribed as directed for severe back pain. The Part D plan denied coverage because the prior authorization criteria were not met. 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 documentation shows the doctor prescribed Lidocaine patches to treat severe back pain for an enrollee awaiting back surgery. The prescriber statement shows the drug was not prescribed for pain associated post-herpetic neuralgia, pain associated with diabetic neuropathy, or pain associated with cancer-related neuropathy. The Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gammagard Liquid 10% to treat multifocal motor neuropathy. The Part D Plan denied the request because the information received did not support that the plans prior authorization criteria had been satisfied. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The medical records show your doctor prescribed Gammagard to treat a diagnosis of multifocal motor neuropathy. This is a medically accepted indication. However, your medical records, including EMG testing and laboratory testing, do not satisfy the plans prior authorization criteria, that are approved by Medicare, to allow payment for the drug requested.  A physician reviewed your appeal and determined that the plan is not required to cover Gammagard.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ezetimibe 10 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other drugs on a lower cost-sharing tier. 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.Ezetimibe is a generic drug on Tier 3 of the plans formulary. There are no generic 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 Orphengesis Forte 50-770-60 milligrams tablets to treat chronic pain due to cervical radiculopathy, post laminectomy syndrome of cervical region, cervical stenosis. The Part D plan denied your request for a non-formulary exception. 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 records submitted at the reconsideration level. The prescriber has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. 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

You requested Megestrol acetate 625 milligram\5 milliliter suspension prescribed as directed for anorexia related to malignant neoplasm of the colon, unspecified. The Part D plan denied your request because the Food and Drug Administration has not approved this drug for your diagnosis. 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 record shows you were prescribed Megestrol acetate to treat your condition. The Medicare approved compendia do not support the use of this drug for your condition based n the medical records submitted. Additionally, prior authorization criteria are not met. 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 the Megestrol acetate because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 200 milligram tablets prescribed daily for medication-related fatigue. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Modafinil for medication-related fatigue. 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.