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

At issue is Menactra vaccine prescribed and administered to you by your physician. You are requesting reimbursement for the Menactra vaccine administered on July 31, 2020. We received an auto-forwarded request from the Plan to reconsider the appeal.We conducted an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you were administered the Menactra vaccine in your physicians office. Medicare rules state that if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, a physicians statement was also provided showing you paid for the vaccine for the total amount charged. We determined that the plan is required to reimburse you for the amount of total cash price paid, minus any applicable tiered copayment/coinsurance amount.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Trumenba vaccine prescribed and administered to you by your physician. You are requesting reimbursement for the Trumenba vaccine administered on July 31, 2020. We received an auto-forwarded request from the Plan to reconsider the appeal.We conducted an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. No additional documentation was requested from the enrollee.The record shows you were administered the Trumenba vaccine in your physicians office. Medicare rules state that if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The documentation provided includes a letter from the plan indicating the Trumenba was approved. In this case, a physicians statement was provided showing you paid for the vaccine for the total amount charged. We determined that the plan is required to reimburse the enrollee the amount of total cash price paid, minus any applicable tiered copayment/coinsurance amount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Butorphanol Tartrate Powder. The Part D plan denied the request because bulk powders are not Food and Drug Administration approved. We received a reconsideration request. We performed an independent and de novo review. We received all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The records show a compound drug with an ingredient not covered by the plan. Drugs compounded from bulk powders are not Food and Drug Administration approved and are not covered under Part D. A physician reviewed your appeal and determined that the plan is not required to cover Butorphanol Tartrate Powder.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone/Acetaminophen 10 milligram/325 milligram tablets prescribed two to three times daily for the enrollees condition. The Part D plan denied your request for a tiering exception because the prescriber did not address all alternatives were tried and failed. 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.Oxycondone/Acetaminiphen is a generic drug on Tier 3 of the plans formulary. Your doctor submitted a supporting statement. The statement did not address why all alternative lower-tier medication on the plans formulary would not work for you. All generic drugs on lower tiers have not been tried. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz XR 11 milligram tablets for rheumatoid arthritis. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The physician submitted a supporting statement. The documentation indicates the physician had prescribed Xeljanz XR to treat rheumatoid arthritis. The Medicare approved compendia support the use of the requested drug for your condition.However, the records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. The physician did not indicate all alternatives to treat the enrollees 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 Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate HCL 10 milligram tablets prescribed twice daily for chronic fatigue. The Part D plan denied your request because the provided diagnosis does not meet the criteria of 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Methylphenidate HCL to treat your chronic fatigue. The use of the requested drug to treat the provided diagnosis is an off-label use. 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 Methylphenidate HCL because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pimecrolimus 1 percent cream prescribed as directed for vitiligo. The Part D plan denied your request because the Food and Drug Administration has not approved this drug for your diagnosis. 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 records show your doctor prescribed Pimecrolimus to treat your vitiligo. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees 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 Pimecrolimus. A Part D drug must be prescribed for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Keytruda 100 milligram/4 milliter vial prescribed daily for locally advanced urothelial carcinoma of the renal pelvis. The Part D plan denied your request for a tiering exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read 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.Keytruda is not on the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to 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 formulary 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 Saxenda 18 milligrams/3 milliliters injection pen prescribed for morbid (severe) obesity due to excess calories. The Part D plan denied your request because this type of drug is excluded from Part D coverage. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. 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 drugs 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 Dronabinol 2.5 milligram tablets prescribed twice daily for open angle glaucoma. The Part D plan denied your request because the provided diagnosis does not meet the criteria of 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Dronabinol 2.5 milligram tablets to treat your open angle glaucoma. 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 Dronabinol because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligrams/milliliter prefilled syringe prescribed for the enrollees condition. 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.Prolia 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

At issue is Xeljanz 11 milligram tablet prescribed daily for the treatment of rheumatoid arthritis. The Part D plan denied coverage because the prior authorization criteria was not met. 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 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan would likely cause harm or not be as effective as the requested drug.  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 Vyvanse 70 milligram tablets prescribed daily for unknown diagnosis. 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.Vyvanse is not listed on your plans formulary. Your physician submitted a supporting statement. The supporting statement did not indicate all the formulary alternatives would be ineffective or that 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 Vyvanse.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets prescribed as directed for atrial fibrillation. The Part D plan denied your request for a tiering exception. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Eliquis 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 Velphoro 500 milligram chewable tablets prescribed as directed. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked the prescriber to send us information regarding the enrollees condition. We did not receive the documentation requested.No medical records were provided by the prescriber to support the enrollees need for Velphoro. 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 Velphoro.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide EC 3 milligram capsules prescribed as directed. At initial determination and redetermination, the diagnosis of non-infective gastroenteritis and colitis was given. 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. At reconsideration a diagnosis of lymphocytic-plasmacytic colitis 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 Budesonide EC.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Mesalamine Enema 4 gram/60 milliliter prescribed for ulcerative colitis with rectal bleeding. The plan denied the request as the drug is covered at the cost-sharing Tier listed in the 2021 Drug Guide and there is no explanation why the alternative drugs in a lower tier wouldnt work just as well. 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.Mesalamine is a generic drug on Tier 4 of the plans formulary. There is no supporting documentation of reasons why all other generic drugs on the lower tiers of the plans formulary, of the same type, have not been tried. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligrams per 2 milliliter pen to be given subcutaneously for asthma - mild, mast cell activation syndrome. The Part D plan denied the drug because it was not medically necessary. The plan requires prior approval before covering some 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level.Dupixent is being requested to treat  asthma - mild, mast cell activation syndrome. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage..A physician reviewed your appeal and determined that the plan is not required to cover the Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xolair 150 milligrams per 1 milliliter to be given subcutaneously for asthma-mild, mast cell activation syndrome. The Part D plan denied the drug because it was not medically necessary. The plan requires prior approval before covering some 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level.Xolair is being requested to treat asthma-mild, mast cell activation syndrome. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.A physician reviewed your appeal and determined that the plan is not required to cover Xolair.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed for circadian rhythm sleep disorder. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted at the reconsideration level. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  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 Balversa 4 milligram tablets prescribed twice daily for advanced papillary bladder cancer. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show you have a diagnosis of advanced papillary bladder cancer. Your provider submitted a supporting statement that indicated you have not been on platinum therapy in the past. You were initially diagnosed in 2013 with noninvasive bladder cancer. In 2019, your cancer showed signs of progression with multiple tumors in the bladder and a large mass in the kidney. You were not a candidate for platinum therapy due to advanced age and renal insufficiency; therefore, you were started on Keytruda as a first line of treatment for patients unable to start platinum therapy. Next generation sequencing tests showed a FGFR3 mutation. The Medicare approved compendia contain citations to support the drug at issue is a second line of therapy for patients with an FGFR3 mutation. A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% topical patches prescribed as directed for chronic low back pain. 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 reviewed your appeal carefully. We reviewed all documentation available.The documentation shows the doctor prescribed Lidocaine 5% topical patches to treat chronic low back pain. However, 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 5% topical patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Febuxostat 80 milligram tablets to treat gout. The Part D plan denied your request for a tiering exception for this covered drug at a lower cost tier. 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 documentation shows Febuxostat was prescribed; however, Febuxostat is not on the plans formulary. Therefore, cannot be eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception.