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

You requested Nulojix 337.5 milligram infusion prescribed every 28 days for prophylaxis of rejection post kidney transplant. The Part D plan denied the request because drugs that could be covered under Part B are not eligible to be covered under the 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 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 record shows that the enrollee received a kidney transplant on August 13, 2020. According to Medicare records, the enrollee was entitled to Part A coverage on November 1, 2010. Medicare law excludes coverage for any drug under the Part D program for which payment would be available under Parts A or B. Coverage is available under Part B for drugs used in immunosuppressive therapy furnished to an enrollee covered under Part A at the time of the transplant. The enrollee was covered under Part A at the time of the transplant. Therefore, coverage may be made under Part B.The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Praluent 150 milligrams per milliliter prescribed for hyperlipidemia with coronary artery disease. The Part D plan denied your request for a tiering exception because Praluent is a non-formulary drug and has already been approved for a 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 records show Praluent is being prescribed for hyperlipidemia with coronary artery disease. The information received from the plan indicates that a formulary exception has been approved for the non-formulary drug Praluent. When a formulary exception is made, a tiering exception cannot be allowed. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the Praluent at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Meloxicam 10 milligram capsule prescribed for osteoarthritis. The Part D plan denied your request because the documentation did not support an off-formulary exception since not all preferred drugs were previously tried. 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 physician submitted a supporting statement. The prescriber statement shows the physician had prescribed Meloxicam to treat osteoarthritis. The Medicare approved compendium does support the use of this drug for osteoarthritis. However, the records do not show why preferred alternatives on the plans formulary for the same condition have not been tried. The documentation does not show that the enrollee has tried all formulary alternatives, 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 Meloxicam 10mg capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Flector 1.3 percent topical patch for chronic pain. 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 Flector for a diagnosis of chronic hip pain. In review of the Medicare approved compendium, chronic pain is not a medically accepted indication for Flector. This medication is only covered for acute pain.A physician reviewed your appeal and determined that the plan is not required to cover the Flector at issue because it does not meet the definition of a Part D drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligrams prescribed twice daily for atrial fibrillation. The Part D plan denied your request for a tiering exception because the drug is on a preferred tier; the plan could not approve a tiering exception for a drug on a preferred tier to a generic 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. Eliquis is a brand drug on Tier 3 of the plans formulary. The prescriber statement shows the enrollee experienced bleeding on Xarelto and did not achieve therapeutic levels with Warfarin. 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 Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine 8 milligram/Naloxone 2 milligram sublingual tablets  prescribed every eight hours for chronic pain. 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 Buprenorphine 8 milligram/Naloxone 2 milligram sublingual tablets to treat your chronic pain. 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. Your prescriber did not indicate all alternatives to treat your condition were tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine 8 milligram/Naloxone 2 milligram sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rinvoq 15 milligrams prescribed twice a day for the diagnoses of Crohns disease and ankylosing spondylitis. The Part D plan denied your request because the drug is non-FDA approved for the reported diagnoses. 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 Medicare regulations and your plans information. The prescriber submitted a request to increase the dosage of Rinvoq to 30 milligrams per day and stated that the enrollee did not have an adequate response to other medications. The prescriber notes a CELEST trial that found higher doses of Rinvoq were associated with better Crohns disease outcomes and increased rates of clinical and endoscopic remissions. However, Medicare approved compendia do not support the use of this drug for your condition. Medicare requires that the drug must be prescribed for a medically accepted indication that is approved by the FDA or supported by one or more citations in Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Rinvoq.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Isotretinoin 30 milligram capsules prescribed twice daily for a oligodendroglioma of the temporal lobe. The Part D plan denied your request because the drug was not prescribed for 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.Your medical records show your doctor prescribed Isotretinoin for your oligodendroglioma of the temporal lobe. The Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of the noted condition.  There was no clinically relevant, peer-reviewed, medical literature from a Medicare approved journal submitted to support this request.  The requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. A physician reviewed your appeal and determined that the plan is not required to cover Isotretinoin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine Hydrochloride 2 milligrams sublingual prescribed 45 tablets per 30 days for chronic back pain and sacroiliac joint pain. The Part D plan denied your request because the enrollees diagnoses did not support 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 medical records show Buprenorphine Hydrochloride 2 milligrams was prescribed for the enrollees chronic pain. However, the Medicare approved compendia do not support the use of this drug for your condition. The compendia indicate the sublingual tablets are only intended for use in the treatment of opiate dependence and should not be used for pain relief.A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spiriva Respimat 2.5 micrograms/inhalation. The Part D plan denied your request because the documentation did not support an off-formulary exception since not all preferred drugs were previously tried. 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 called the prescriber to request additional information regarding your diagnosis. Specifically, we asked the prescriber to identify the condition requiring treatment with Spiriva Respimat.  However, we did not receive a return call prior to the appeal decision deadline.The documentation in the case file does not identify the condition for which the enrollee has been prescribed Spiriva Respimat. As such, it cannot be determined if the use of this drug for the enrollees condition is supported by Medicare approved compendia.Also, the documentation does not show why the enrollee cannot try, or is intolerant to all alternative drugs on the plans formulary.  Specifically, the documentation submitted does not support that the enrollee has tried and failed, or is unable to formulary alternative such as Atrovent. A physician reviewed your appeal and determined that the plan is not required to cover Spiriva Respimat.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxiconozole Nitrate 1 % cream prescribed for the diagnoses of onychomycosis (tinea unguium). The Part D plan denied your request because the drug is non-FDA approved for the reported diagnoses. 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 Medicare regulations and your plans information. Your prescriber submitted information that show you have failed other medication treatments including Clotrimazole, Ketoconazole, Nystatin Cream, and Ciclopirox. However, Medicare approved compendia do not support the use of this drug for your condition. Medicare requires that the drug be prescribed for a medically accepted indication that is approved by the FDA or supported by one or more citations in Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Oxiconazole Nitrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rozerem 8 milligram tablets prescribed for bipolar disorder, unspecified. The Part D plan denied your request for a tiering exception because the drug had already been approved for a non-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. We also researched Medicare law and the plans rules.The documentation in the record shows that Rozerem is covered for the enrollee through a formulary exception. Medicare law and plan rules do not allow tiering exceptions for non-formulary drugs being covered through a formulary exception. 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 Rozerem 8 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligrams/milliliter prescribed once every six months for postmenopausal osteoporosis. 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. We also researched Medicare systems and reviewed the enrollment data available.The records show you prescribed Prolia 60 milligrams/milliliter to treat the enrollees postmenopausal osteoporosis. The Medicare approved compendia do support the use of this drug for this condition. The plan requires 1) the enrollee tried and failed one of the following drugs: Alendronate, Risedronate or Ibandronate;  and (2) a trial of zoledronic acid (generic Reclast) before they will cover the requested drug. Medical records submitted do not indicate that prior authorization criteria have been met. A physician reviewed your appeal and determined that the plan will not cover Prolia 60 milligrams/milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mekinist 0.5 milligram tablets prescribed for intrahepatic bile duct carcinoma, metatstatic cholangiocarcinoma with BRAF V600E. 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 Mekinist for your diagnosis of metatstatic cholangiocarcinoma. However, the Medicare approved compendia do not support the use of this drug for your condition.  There was no peer-reviewed clinically relevant, medical literature from an approved journal submitted to support this appeal.   Therefore, the drug at issue is not being prescriber for a medically accepted indication as defined by Medicare law.   A physician reviewed your appeal and determined that the plan is not required to cover Mekinist.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Acetylcysteine 200 milligrams/milliliter prescribed for your diagnosis of pneumonia. 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 record shows your doctor prescribed Acetylcysteine for your diagnosis of pneumonia. However, this drug is eligible for coverage under Medicare Part B. The drug at issue is used with a nebulizer machine. Supplies that are used in durable medical equipment are covered under Part B.We determined that the plan is not required to cover Acetylcysteine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kesimpta 20 milligram/0.4 milliliter injection pen prescribed as directed for multiple sclerosis. The Part D plan denied your request because the documentation did not support an off-formulary exception since not all preferred drugs were previously tried. 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 prescriber statement shows the physician had prescribed Kesimpta to treat your multiple sclerosis. The Medicare approved compendium does support the use of this drug for multiple sclerosis. However, the records do not show why you cannot take other drugs on your plans formulary for your condition. Specifically, the prescriber statement shows the enrollee failed treatment with Capaxone. The documentation does not show that the enrollee has tried all preferred drugs, including Tecfidera.A physician reviewed your appeal and determined that the plan is not required to cover Kesimpta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 75 microgram tablets prescribed for post-procedural hypothyroidism. The Part D Plan denied your request for a tiering exception because the drug is already being provided at the lowest cost-share amount allowed by the plan and no explanation why any of the lower cost drugs cannot be taken. 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 Medicare rules and the plans formulary.Synthroid is a brand drug on Tier 2 of the plans formulary. The physician submitted a statement that the enrollee was allergic to Levothyroxine. There are no branded drugs of the same type on 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 Synthroid at a lower cost-sharing amount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24-26 milligram tablets prescribed twice daily for congestive heart failure. The Part D Plan denied your request for a tiering exception because the drug is already being provided at the lowest cost-share amount allowed by the plan. 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 Medicare rules and the plans formulary.Entresto 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. Medicare rules permit a plan to grant an exception to its tiering structure so long as there is a drug of the same type in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. 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 Entresto at a lower cost-sharing amount.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Saxenda 3 milligrams/0.5 milliliters injection pen prescribed for obesity. The Part D plan denied your request because this type of drug is excluded from Part D coverage. 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 Saxenda because drug used for weight loss 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 Dextroamphetamine/Amphetamine XR 20 milligram capsules prescribed daily for fatigue due to multiple sclerosis and hypersomnia. The Part D plan denied your request 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 prescriber statement shows the doctor prescribed Dextroamphetamine/Amphetamine to treat fatigue due to multiple sclerosis and hypersomnia. However, the Medicare approved compendia do not support the use of this drug for the condition: fatigue due to multiple sclerosis and hypersomnia.A physician reviewed your appeal and determined that the plan is not required to cover Dextroamphetamine/Amphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha SureClick 140 milligram/milliliter autoinjector pen prescribed as directed. The Part D plan denied your request for a tiering exception because there are no lower tier brand drugs available on the plans formulary to treat the enrollees condition. 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. Repatha SureClick 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 cover Repatha SureClick.