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

At issue is Propafenon Hydrochloride 300 milligrams prescribed three times daily for atrial flutter. The Part D Plan denied your request for a tiering exception because an explanation of why alternative drugs listed in a lower tier would not work. 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. Propafenon Hydrochloride  is a generic drug on Tier 3 of the plans formulary. The prescriber statement said Eliquis and Metoprolol Tartrate did not help the enrollees condition. However, the plans formulary includes Amiodarone Hydrochloride, Quinidine Sulfate, and Sotalol Hydrochloride that are the same class as Propafenon Hydrochloride on Tier 2. The statement did not address why these drugs did not or would not work for the enrollee. All drugs on lower tiers have not been tried. Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Vyvanse 70 milligrams prescribed daily for attention deficit disorder. Upon review, the Part D plan denied coverage because prior approval is required 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 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 plan requires a condition of attention deficit disorder, attention deficit/hyperactivity disorder, or moderate to severe binge eating disorder before they will cover the drug. The records received at this level of appeal show Vyvanse is being requested for the treatment of attention deficit disorder.A physician reviewed your appeal and determined that the plan is required to cover the Vyvanse.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a Cimzia Starter Kit prescribed for Blau syndrome and inflammatory arthritis. The Part D plan denied your request because your diagnosis is not a Food and Drug Administration supported 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 your doctor prescribed Cimzia to treat your Blau syndrome and inflammatory arthritis. However, the Medicare approved compendia do not support the use of this drug for your condition. As such, Cimzia is not covered under the Medicare Part D benefit for your condition.A physician reviewed your appeal and determined that the plan is not required to cover the Cimzia Starter Kit because you do not have a medically accepted indication per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 250 milligram tablets prescribed daily for major depressive disorder. The Part D plan denied your request because drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.The medical records show Armodafinil was prescribed to treat major depressive disorder. However, the Medicare approved compendia do not support the use of this drug for this condition. The prescriber statement states you also have obstructive sleep apnea. However, there are no medical records to support this diagnosis. The drug was not prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tafinlar 75 milligrams capsule to treat hairy cell leukemia, in relapse. The Part D plan denied the request stating that the provided diagnosis is a non-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 medical records show the doctor prescribed Tafinlar to treat hairy cell leukemia, in relapse. However, the Medicare approved compendia do not support the use of this drug for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Tafinlar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis, 5 milligram tablets prescribed for history of pulmonary embolism. The Part D Plan denied your request for a tiering exception because there were no other brand drugs appropriate to treat your condition 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. Eliquis is a brand name drug on Tier 3 of the plans formulary. There are no brand name drugs of the same type on the lower cost sharing tiers. If there are no brand name drugs of the same type on a lower tier, the drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover the Eliquis at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Deferasirox 500 milligrams daily prescribed for homozygous hemachromatosis. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. 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 your doctor prescribed Deferasirox to treat hereditary hemochromatosis. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Deferasirox.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nucala Solution, auto-inject, 100 milligrams/milliliter prescribed daily for moderate persistent asthma, uncomplicated. The Part D plan denied your request because Nucala Solution is not Food and Drug Administration approved for your condition. 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 Nucala Solution to treat your moderate persistent asthma, solo therapy. Your asthma is not diagnosed as severe, complicated. The Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Nucala Solution because you do not have a medically accepted indication per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Combivent Respimat 20/100 micrograms prescribed as directed for chronic obstructive pulmonary disease and asthma. 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. 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 your doctor prescribed Combivent Respimat to treat your chronic obstructive pulmonary disease and asthma. The Medicare approved compendium supports the use of this drug to treat your condition. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Combivent Respimat because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nulojix 250 milligram vial for the prophylaxis of renal transplant rejection. The Part D plan denied your request because Part B pays for drugs used to prevent transplant rejection for a beneficiary who was eligible for a Medicare covered organ transplant. 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. Medicares Part B local policy states that immunosuppressive drugs are covered only for the specific labeled indications and approval for marketing by the FDA. The Medicare Part B rules state that parenteral Belatacept (Nulojix) is not proven to be safe when administered in the home setting, and therefore will be denied under Medicare Part B as not medically necessary when provided in that setting. The case record indicates that Nulojix will be administered in the home. Nulojix would therefore not be eligible for coverage under Medicare Part B in this case.Nulojix is not on the plan's formulary. 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 Reviewers opinion is that the formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate 500 milligrams prescribed daily for birdshot retinochoroidopathy. The Part D plan denied your request because it 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 Mycophenolate 500 milligrams daily to treat your birdshot retinochoroidopathy. 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 Mycophenolate 500 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Incruse Ellipta 62.5 micrograms inhalation prescribed for chronic obstructive pulmonary disease. 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 documentation does not satisfy the Plans coverage criteria.  However, the prescriber has indicated why all alternatives required by the Plan would likely not be as effective as the requested drug for you, or would likely cause adverse reaction(s). The prescriber sent a letter dated February 16, 2021, clarifying your medical history and stating that you had adverse effects with Spiriva.  Therefore, an exception to the Plans coverage criteria is medically necessary.A physician reviewed your appeal and determined that the Incruse Ellipta 62.5 micrograms inhalation is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Venetoclax 100 milligram tablets prescribed for acute myeloid 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 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. We also researched Medicare systems and reviewed the enrollment data available.The medical records show you were prescribed Venetoclax in combination with Vidaza to treat acute myeloid leukemia. The Medicare approved compendia do support the use of this drug for your condition. However, the plan requires that prior authorization criteria be addressed by your prescriber. 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 Venetoclax.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tresiba Flextouch 200 milligrams prescribed daily for diabetes. The Part D plan denied your request for a tiering exception. We received an expedited auto-forwarded reconsideration request from the coverage level. 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. Tresiba is a brand drug that is not on your plans formulary. Additional documentation was requested from your doctor regarding your condition and why the alternative drugs on your plans formulary would not work for you. Medicare denied a formulary exception because you did not try all of the alternative drugs to treat your condition. A tiering exception cannot be allowed for a drug that is not on the plans formulary. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Tresiba Flextouch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Procrit 20000 units/milliliter prescribed for sickle cell anemia. 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 the drug for sickle cell anemia. 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 Jevity 1.5 cal prescribed four times daily for achalasia. The Part D plan denied your request because Medicare has excluded over-the-counter drug products 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 the Jevity because it is an over-the-counter drug. Nonprescription, or over-the-counter drugs, 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 reimbursement cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 75 microgram tablets prescribed daily for hypothyroidism. 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.Synthroid is a brand drug on Tier 4 of the plans formulary. The prescriber statement shows the enrollee has tried Levothyroxine, a generic drug, which caused adverse reactions. However, 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 the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Synthroid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Lidocaine patch to treat an inguinal hernia. The Part D plan denied the request stating that the Medicare requirements for covering the drug 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 information submitted at the reconsideration level. 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 requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estring Ring 2 milligrams prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue was covered as a formulary exception and was not eligible 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.Estring Ring is a non-formulary drug. Non-formulary drugs are 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 Cyclobenzaprine 5 milligrams prescribed as directed for right shoulder pain. The Part D plan denied your request because it 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 Cyclobenzaprine 5 milligrams to treat your right shoulder pain. 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 Cyclobenzaprine 5 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Lipitor 10 milligrams prescribed daily for hyperlipidemia. The Part D Plan denied the request for a 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 your prescriber to send us a supporting statement to show why the brand drug Lipitor is medically necessary. We received the documentation and included it in our review.The records show that you cannot take other drugs on your plans formulary for your condition. Specifically, the drugs on the formulary caused myalgia.A physician reviewed your appeal and determined that the plan is required to cover Lipitor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydroquinone 4% cream prescribed daily for prevention of skin cancer. The Part D plan denied your request because the drug is excluded from coverage. 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.We determined that the plan is not required to reimburse Hydroquinone 4% cream because it is not approved by the Food and Drug Administration. 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

At issue is Valacyclovir HCl 500 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other generic 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.Valacyclovir is a generic drug on Tier 2 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.