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

You requested Interferon Alfa 2b  prescribed for malignant neoplasm of unspecified conjunctiva.  The Part D plan denied your request. We received the case to perform 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 levelThe record shows the Interferon alfa 2b is a compounded drug and each ingredient is reviewed individually. Medicare Part D does not cover drugs that do not meet the definition of a Part D drug. Therefore, we determined that the plan is not required to cover or reimburse for the Sodium Chloride Bacteriostatic. We determined that the Medicare rules for the Intron A have been met. Medicare rules allow a Part D plan to manage its formulary by requiring prior authorization, step therapy or quantity limits. Prior authorization has been met for the Intron A. Therefore, the plan is required to cover the Intron A ingredient included in the Interferon Alfa 2b compound.A physician reviewed your appeal and determined that the plan is not required to cover Sodium Chloride Bacteriostatic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablet prescribed twice daily for persistent atrial fibrillation. The Part D plan denied the request for a tiering exception.We received the case to perform 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 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.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3 % patch prescribed for acute pain due to minor strain of lower back. The Part D plan denied the request.We received the case to perform 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Epolamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 microgram inhalation prescribed as directed for emphysema, unspecified. The Part D plan denied your request.We received the case to perform 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Albuterol Sulfate 0.63 milligram/3 milliliter vial prescribed for the treatment of asthma/chronic obstructive pulmonary disease. The Part D plan denied the enrollees request.We received the case to perform 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. The record shows the Albuterol Sulfate is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Albuterol Sulfate. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Diazepam 5 tablets prescribed for chronic anxiety. The Part D plan denied the request because the plans prior authorization requirements were not met.  We received the case to perform 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 Part D plan has prior authorization requirements that have to be met before coverage of this drug is allowed. The available medical records do not address the plans coverage requirements for Diazepam. During this review, a request was submitted to the prescriber to address the plans prior authorization requirements and to provide medical records and a prescriber statement of medical necessity to support that the coverage requirements have been met. We received answers to questions on a form; however, no supporting medical records or prescriber statement of medical necessity was submitted. It is not possible to confirm that the plans coverage criteria have been satisfied with the available documentation. 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 Dalfampridine ER 10 milligram tablets prescribed as directed for multiple sclerosis. The Part D plan denied your request.We received the case to perform 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.Your medical records show your doctor prescribed Dalfampridine ER to treat your multiple sclerosis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. 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 Dalfampridine ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 microgram inhalation powder prescribed daily for chronic obstructive pulmonary disease. The Part D plan denied the request.We received the case to perform 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. The doctor prescribed Anoro Ellipta to treat the enrollees chronic obstructive pulmonary disease. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Anoro Ellipta. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100-62.5 microgram inhaler prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform 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. Trelegy Ellipta 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

At issue is Viibryd 10 milligram tablet prescribed for bipolar disorder, current episode mixed, moderate. The Part D plan denied the request. We received the case to perform 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 indicates that Viibryd 10 milligram tablet is requested to treat bipolar disorder, current episode mixed, moderate. 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 Viibryd.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue Repatha Sureclick 40 milligram/milliliter injection prescribed for pure hyperglyceridemia. The Part D plan denied the request.We received the case to perform 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.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work. We received the documentation and included it in our review.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gammagard 10% solution prescribed for the treatment of nonfamilial hypogammaglobulinemia and common variable immunodeficiency. The Part D plan denied the request. We received the case to perform 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 the doctor prescribed Gammagard to be administered to the enrollee in the home for the treatment of nonfamilial hypogammaglobulinemia and common variable immunodeficiency. The prescribers statement of medical necessity documents that this is a primary immune deficiency. Intravenous immune globulin may be allowed under Part B in the home for a diagnosis of primary immune deficiency. We determined that the Medicare Part D plan is not required to cover Gammagard. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80 milligram/milliliter auto injector prescribed as directed for psoriasis vulgaris. The Part D plan denied your request.We received the case to perform 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Taltz.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nubeqa 300 milligram tablets prescribed for metastatic castrate-resistant prostate cancer. The Part D plan denied the 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 records indicate the enrollee was initially diagnosed with prostate cancer in 2007. The enrollee was treated with Lupron and had disease progression. The enrollee now has a diagnosis of metastatic castration-resistant prostate cancer. The prescriber has submitted Medicare approved journal articles detailing a clinical trial to support the use of the drug for the enrollees condition. Therefore, the drug at issue can be considered medically accepted for the enrollees condition.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 Prolia 60 milligram/milliliter syringe given every 6 months prescribed for postmenopausal osteoporosis. The Part D plan denied the request as it is approved under Part B due to no indication the enrollee is picking up the drug at the pharmacy and there is indication it is too soon to refill the medication.We received the case to perform 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 indicate Prolia 60 milligram/ milliliter is given at a facility and is order every 6 months. The prescriber indicates the pharmacy is dispensing the medication to the patient and not to the doctors office. The drug is eligible for Part D drug coverage. However, the medical records show that Prolia 60 milligram/milliliter was administered at the prescribers office on July 26, 2021. Therefore, it is too soon for a refill as it is ordered and given every 6 months.   A physician reviewed your appeal and determined that the plan is not required to cover Prolia 60 milligram/milliliter syringe.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aquasol 50000 units/milliliter injection prescribed for vitamin A deficiency. The Part D plan denied the 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.We determined that the plan is not required to cover Aquasol because it was a prescription vitamin product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Mydayis ER 50 milligram capsules prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform 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. This drug is not included on your plans formulary. Per Medicare rules, 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

At issue is Thalomid 50 milligram capsules prescribed for arteriovenous malformation of small intestine. The Part D plan denied the 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 submitted documentation indicates the prescriber ordered Thalomid for arteriovenous malformation of small intestine. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lynparza 150 milligram tablets prescribed for thymic carcinoma. The Part D plan denied the 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 submitted documentation indicates the prescriber ordered Lynparza for thymic carcinoma. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There were no Medicare approved journal articles submitted to support the use of the drug for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trokendi XR 100 milligram capsule prescribed for lumbar radiculopathy. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows Trokendi was prescribed to treat lumbar radiculopathy. 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 Trokendi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Lantus Solostar 100 units/milliliter pen prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.We received the case to perform 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.Lantus Solostar is a biologic on Tier 3 of the plans formulary. There are no biologics of the same type on the lower cost sharing tiers. Therefore, this biologic is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine-Prilocaine 2.5%-2.5% cream prescribed as a topical anesthetic. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. According to Medicare rules, the requested drug cannot be approved for separate payment under Part D when it's for treatment on an enrollee who is receiving dialysis. Medicare records show the enrollee is actively receiving dialysis. Therefore, the Lidocaine-Prilocaine cream must be billed by the renal dialysis facility. We determined that the plan is not required to cover the Lidocaine-Prilocaine cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 2 milligram sublingual tablets prescribed for chronic pain syndrome. The Part D plan denied the 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 submitted documentation indicates the prescriber ordered Buprenorphine Hydrochloride for chronic pain syndrome. The Medicare approved compendia do not support the use of the drug at issue, in sublingual tablet formulation, for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gonal-F RFF Redi-Ject 900 international units/1.5 milliliter solution prescribed for male infertility. The Part D plan denied the 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.We determined that the plan is not required to cover Gonal-F RFF Redi-Ject because it was prescribed for sexual dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Ropinorole Hydrochloride 4 milligram extended release tablets prescribed for Parkinsons disease. The Part D plan denied the request.We received the case to perform 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.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Ropinirole Hydrochloride extended release.