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

You requested Risedronate Sodium 150 milligram tablets prescribed as directed for gastroesophageal reflux disease without esophagitis, Lymes disease, unspecified and polymyalgia rheumatica. 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 your doctor prescribed Risedronate Sodium to treat your gastroesophageal reflux disease without esophagitis, Lymes disease, unspecified and polymyalgia rheumatica. 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 Risedronate Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cresemba 186 milligram capsules. The Part D plan denied the request for coverage.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 documentation indicates that Cresemba has been prescribed to prevent an invasive aspergillus and/or mucormycosis infection in an enrollee with pure erythroid leukemia, not in remission, and profound neutropenia. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Econazole Nitrate 1% cream prescribed for tinea corporis. The Part D plan denied the request for coverage.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 does not satisfy the plans coverage criteria for this medication. 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: Unfavorable

At issue is Xifaxan 550-milligram tablet to treat irritable bowel syndrome with diarrhea. The Part D plan denied the request. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation provided addressed the plans coverage criteria, and those criteria were not satisfied. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 0.25-0.5 milligram dose pen prescribed daily for the enrollees condition. The Part D plan denied your 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.Ozempic is a brand drug on Tier 3 of the plans formulary. A supporting statement and medical records were requested from your doctor; however, no further documentation was received. 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 Harvoni 400 milligram tablets prescribed as directed for hepatitis C, genotype 1a. 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 Harvoni to treat your hepatitis C, genotype 1a. 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 Harvoni.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Mavyret (Glecaprevir 100 milligrams/ Pibrentasvir 40 milligrams) tablets, 84 tablets per 28 days.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. The submitted medical records indicate that Mavyret has been prescribed for the treatment of treatment-naive genotype 1b chronic hepatitis C with compensated cirrhosis, which is a medically accepted indication outlined in the Medicare approved compendia. As outlined in the American Association for the Study of Liver Diseases, the recommended regimen for treatment-naive genotype 1b chronic hepatitis C with compensated cirrhosis is a daily fixed-dose combination of Glecaprevir (300 milligrams)/Pibrentasvir (120 milligrams) for a course of eight weeks, which is what has been ordered by the prescriber. The plan has a quantity limit for Mavyret of 84 tablets per 28 days. The drug is included in the Specialty Tier of the plans formulary, which is limited to a recurring monthly supply. The documentation submitted from the plan shows that the prescriber initially requested 168 tablets for 56 days. During this review, the prescriber was contacted and notified of the plans quantity limits. The prescriber then submitted a new prescription for 84 tablets of Mavyret with one refill.Therefore, the submitted medical records support that the Mavyret is being prescribed for a medically accepted indication as outlined in the Medicare approved compendia, that the requirements outlined in the American Association for the Study of Liver Diseases have been met, and that the plans quantity limit has not been exceeded. A physician reviewed the appeal and determined that the plan is required to cover Mavyret.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig solution auto injector 140 milligram/milliliter prescribed for chronic migraines. 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. Your medical records show your doctor prescribed Aimovig solution auto injector 140 milligram/milliliter for your chronic migraines. 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 Aimovig. 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

You requested Amphetamine/Dextroamphetamine 20 milligram tablets prescribed as directed for major depressive disorder, circadian rhythm sleep disorder, unspecified type, and dysthymic disorder. 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 your doctor prescribed Amphetamine/Dextroamphetamine to treat your major depressive disorder, circadian rhythm sleep disorder, unspecified type, and dysthymic disorder. 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 Amphetamine/Dextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch for chronic low back pain. 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.We asked your prescriber to send us information regarding your condition. We also asked for additional medical records or other documentation to show why you need this medication. We did not receive the requested documentation.Your doctor prescribed Lidocaine 5% patch for chronic low back pain. No additional medical records have been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 5 milligram oral tablet prescribed three time daily for muscle spasm of of the neck with Parkinson's disease. 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. 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 documentation shows your doctor prescribed Cyclobenzaprine Hydrochloride to treat your muscle spasm of the neck with Parkinson's disease. 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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carbidopa 25 milligram tablets 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 included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.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 Gleostine 100 milligram capsule prescribed for glioblastoma. 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. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the list, the manufacturer, Nextsource Biotechnology, Llc, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Gleostine. 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 Procrit 10,000 units/milliliter injection prescribed for anemia associated with chronic kidney disease, not on dialysis. 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.A request was submitted to the prescriber to provide a diagnosis, to clarify the medical history, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  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 your appeal and determined that the plan is not required to cover Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prednisone 5 milligram tablet prescribed daily to prevent kidney transplant rejection. 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. We determined that the plan is not required to cover the Prednisone. Medicare records indicate the enrollee received a kidney transplant on March 16, 1995 and July 22, 1999, which were covered by Medicare Part A. Therefore, the transplants were considered Medicare covered transplants and Prednisone is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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 prescribed Oxycodone Hydrochloride 10 milligram oral tablet. 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.At initial determination the diagnosis of chronic pain syndrome was given. However, no medical records were submitted for review.  A request was submitted to the prescriber to provide a diagnosis, to clarify the medical history, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  The prescriber has not sufficiently addressed the plans coverage criteria. 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 Oxycodone Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cosentyx 300 milligram dose-2 pens prescribed weekly for five weeks, then every four weeks for severe plaque and psoriatic arthritis. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria, with supporting medical records, and/or the coverage criteria are not satisfied by the provided documentation.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Benlysta 200 milligram/milliliter solution auto-injector prescribed two injections weekly for the first four doses, then once weekly for systemic lupus erythematosus, nephritis. 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. Your medical records show your doctor prescribed Benlysta to treat your systemic lupus erythematosus, nephritis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Specifically, the requirements include a history of positive antinuclear antibody results, documentation indicating a score of 10 or more for additive, weighted systemic lupus erythematosus diagnostic criteria, and evidence of a claim that the enrollee is currently on systemic lupus erythematosus treatment regimen within the past 90 days comprised of at least one of the required medications. The enrollee must not be treated with another biologic agent in the past 30 days, or has and will discontinue. In this case, the medical records include a positive result for an antinuclear antibody test. In addition, the records provide a kidney biopsy report, which shows an ISN/RPS class V diffuse membranous lupus glomerulonephritis diagnosis. Also, laboratory results reveal a critically low value for the enrollees white blood count level. Further, the medical records support that the enrollee is taking Hydroxychloroquine Sulfate, Mycophenolate Mofetil and Prednisone, and is not being treated with another biologic agent. Lastly, the Plan states paid claim for Prednisone on May 18, 2021, no evidence patent is treated with another biologic agent. As such, the documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Benlysta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Kesimpta 20 milligram/0.4-milliliter pen prescribed for multiple sclerosis. The Part D plan denied your request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. A request was submitted to the prescriber to confirm the diagnosis, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  Without a covered diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.  A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Corlanor 5 milligram prescribed daily for ventricular tachycardia and acute systolic congestive heart failure. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. 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 did not receive the documentation requested.The documentation shows your doctor prescribed Corlanor to treat your ventricular tachycardia and acute systolic congestive heart failure. 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 Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sodium Chloride 0.9% nebulizing solution prescribed for severe asthma, chronic asthma with acute exacerbation, and cough. 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need this medication. We received the documentation and included it in our review.The records shows Sodium Chloride 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 Sodium Chloride. The decision does not address the 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

You requested Cetacaine 20 gram spray administered while in the hospital for a procedure. 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 record shows Cetacaine spray as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover or reimburse you for the Cetacaine spray. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulicity 0.75 milligram/0.5 milliliter pen injector 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. Trulicity 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.