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

At issue is Repatha 140 milligram/milliliter SureClick injection pen prescribed as directed for coronary artery disease involving native coronary artery of native heart, angina presence unspecified. The Part D plan denied coverage because the prior authorization criteria were not met. 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 prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the Plans prior authorization criteria. A response from the prescriber was not received. Your medical records show you were prescribed Repatha to treat your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided do not show the plan's coverage criteria has been met.A physician reviewed your appeal and determined that the plan is not required to cover the Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Azathioprine 50 milligram tablets prescribed for uveitis. 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 Azathioprine for uveitis. In review of the Medicare approved compendia, uveitis is not a medically accepted indication for Azathioprine. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Azathioprine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trikafta 100-75-50 milligram tablets prescribed as directed for cystic fibrosis. 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 reviewed your appeal carefully. We reviewed all documentation available.The documentation shows the doctor prescribed Trikafta to treat cystic fibrosis. However, 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 Trikafta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil 50 milligram tablet prescribed three times daily for secondary pulmonary arterial hypertension. The Part D plan denied your request because the medication did 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. The records show you prescribed Sildenafil 50 milligram tablet three times daily to treat the enrollees secondary pulmonary arterial hypertension. However, the Medicare approved compendia do not support the use of this drug for this condition. For the symptomatic management of pulmonary arterial hypertension (WHO group I), the recommended adult oral dosage of Sildenafil is 5 or 20 milligrams three times daily. The Medicare approved compendia do not support the use of Sildenafil 50 milligram tablets three times daily in the treatment of pulmonary arterial hypertension.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 Botox 200 unit injection prescribed for migraine disorder. 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. Your physician submitted a supporting statement. The supporting statement did not indicate all formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Botox.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Horizant ER 600 milligram tablets prescribed for idiopathic peripheral autonomic neuropathy. 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 Horizant for idiopathic peripheral autonomic neuropathy. 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 Diclofenac sodium 3% topical gel prescribed as directed. The Part D plan denied coverage because the drug was not prescribed for a medically accepted indication. The plan further stated 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 reviewed your appeal carefully. We reviewed all documentation available.At reconsideration a diagnosis of actinic keratosis 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 your appeal and determined that the plan is not required to cover Diclofenac sodium gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Norethindrone Acetate/Ethinyl Estradiol 1 milligram-20 microgram tablets prescribed for the enrollees endometriosis. The Part D plan denied coverage because the drug at issue has formulary criteria that were not met. 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 diagnoses of endometriosis, endometrioma, right lower abdominal pain, abnormal uterine bleeding, and contraception. However, the enrollee does not satisfy the plan's formulary coverage criteria. The drug at issue is not prescribed primarily for contraception.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 Vraylar 1.5 milligram capsules prescribed for the enrollees bipolar I disorder. 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 bipolar I disorder. 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 Vimpat 100 milligram tablets prescribed for seizures. 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 your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Vimpat is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Epclusa 400 milligram-100 milligram tablets for hepatitis C. The Part D plan denied your request for a quantity limit exception request. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates your doctor prescribed Epclusa for hepatitis C. The drug at issue was approved as a specialty drug, which is only approved for a 28 day supply at a time. You are requesting 84 tablets for 84 days at one time. An exception to the quantity limit criteria was not met.Therefore, the plan is not required to cover Epclusa for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide 0.5 milligram/2 milliliter suspension prescribed for allergic rhinitis. The Part D plan denied your request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates you are not taking the drug at issue via a nebulizer. Your doctor prescribed Budesonide suspension for allergic rhinitis. The Medicare approved compendia do not support the use of this drug in this formulation 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 Hetlioz 20 milligram capsules prescribed as directed for non-24 hour sleep-wake cycle. 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 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 Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Retacrit 10,000 units prescribed twice weekly for chronic kidney disease. The Part D plan denied your request because this drug may be eligible for coverage under Parts A or B; therefore, it cannot be covered under 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 the enrollee is using Retacrit for anemia management in conjunction with hemodialysis. End-stage renal disease facilities are responsible for furnishing drugs for anemia management. Therefore, we have determined that the plan is not required to cover the Retacrit.  You may wish to submit this request to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 milligram tablets prescribed daily for type II diabetes. The Part D plan denied your request for a tiering exception. 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.Jardiance 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. There are no lower tiered brand drugs of the same type to treat your condition.A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 20 milligram tablets prescribed for acute embolism and thrombosis of the right jugular vein. 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 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. Xarelto is a brand name drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Temazepam 7.5 milligram capsules prescribed for primary insomnia. 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 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.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Neupro 4 milligrams/ 24 hour patch prescribed restless legs syndrome. 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 an 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. Neupro is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Intravenous Immune Globulin 35 grams weekly. 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 the case file carefully. We reviewed all documentation submitted. The documentation indicates that Intravenous Immune Globulin has been prescriber to treat your progressive inflammatory neuropathy. 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 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 Intravenous Immune Globulin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 97/103 milligram tablets prescribed to treat nonischemic cardiomyopathy. The Part D plan denied the request because the plans coverage requirements for Entresto were not met.  We received an expedited 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.The documentation does not satisfy the plans coverage criteria. The prescriber has indicated that the enrollee will be taking the Entresto with or within 36 hours of taking an angiotensin-converting-enzyme inhibitor. As outlined in the plans coverage requirements, Entresto is contraindicated with concomitant use of an angiotensin-converting-enzyme inhibitor. 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 Latanoprost 0.005% eye drops to treat an intraocular condition, not otherwise specified. 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 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.Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage.  Per the compendia, This drug has not been found by the United States Food and Drug Administration to be safe and effective, and the drug product labeling has not been approved by the Food and Drug Administration. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Mycophenolate Mofetil 500 milligram tablets purchased on the dates of December 8, 2020, through December 15, 2020. The Part D plan denied your request because you had a break in Part D coverage during these dates of service.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any other information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Medicare enrollment records support that you did not have Medicare Part D coverage for the dates of December 8, 2020, through December 15, 2020, when the Mycophenolate Mofetil was purchased. As such, our decision is that the Part D plan is not required to reimburse the charges for the Mycophenolate Mofetil. This decision does not refer to the medical necessity of the requested drug. It only establishes that reimbursement cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Tacrolimus 1 milligram capsules purchased on December 12. 2020. The Part D plan denied your request because you had a break in Part D coverage during this date of service.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any other information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Medicare enrollment records support that you did not have Medicare Part D coverage for the date of December 12, 2020, when the Tacrolimus was purchased. As such, our decision is that the Part D plan is not required to reimburse the charges for the Tacrolimus. This decision does not refer to the medical necessity of the requested drug. It only establishes that reimbursement cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets to treat irritable bowel syndrome with diarrhea. 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 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 provided addressed the plans coverage criteria, and those criteria were not satisfied. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Cinacalcet HCl 30 milligram tablets prescribed for hypercalcemia in renal transplant recipient with persistent hyperparathyroidism. The Part D Plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates you are not currently on dialysis. Your doctor prescribed Cinacalcet HCl for hypercalcemia in renal transplant recipient with persistent hyperparathyroidism. The Medicare approved compendia contain a citation to support the use of this drug for your condition. As the drug was prescribed for a medically accepted indication, coverage can be allowed.A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Evenity 210 milligram pen injector for treatment of osteoporosis. 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 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 physician submitted a supporting statement. The documentation indicates Evenity was prescribed for osteoporosis. However, the physician did not indicate all alternatives on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Evenity.