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

At issue is Buprenorphine 20 micrograms per hour patch every seven days for lumbar, thoracic, and sacroiliac pain. The Part D plan denied the request because of concurrent use of an opioid and a benzodiazepine. 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.We asked you to send us a supporting statement to show why the Buprenorphine is medically necessary. We received the documentation and included it in our review.The prescriber provided a statement that the enrollee required both the Buprenorphine and a benzodiazepine and that oral opioids are not appropriate due to a history of substance abuse.We determined that the plan is required to cover the Buprenorphine patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Azathioprine 50 milligram tablets prescribed daily for polyarthritis and mixed connective tissue disease. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 record shows you were prescribed Azathioprine for polyarthritis and mixed connective tissue disease. In review of the Medicare approved compendia, polyarthritis and mixed connective tissue disease are not medically accepted indications for Azathioprine. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Azathioprine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Medroxyprogesterone. The Part D plan denied a request for this compounded drug because you did not have a medically accepted indication. We received an expedited reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The documentation indicates that Medroxyprogesterone was prescribed to treat prevention of corneal melt from a Boston type 1 keratoprosthesis. However, the Medicare approved compendia do not support the use of this specific drugs ingredient of Medroxyprogesterone Acetate for the enrollees condition. The second ingredient of sterile water is not considered a Part D drug. A physician reviewed your appeal and determined that the plan is not required to cover Medroxyprogesterone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cinacalcet HCL 30 mg tablets to treat secondary hyperparathyroidism in an enrollee with chronic kidney disease who is not on dialysis. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 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 this condition. 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 Cinacalcet HCL because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Quinine Sulfate 324 milligram capsules prescribed for nocturnal leg cramps. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 record shows you were prescribed Quinine Sulfate for nocturnal leg cramps. In review of the Medicare approved compendium, nocturnal leg cramps is not FDA approved for this off label indication. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Quinine Sulfate at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Viberzi 100 milligram oral tablets prescribed daily for collagenous colitis. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. 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. Viberzi is a brand drug on Tier 5, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vemlidy 25 milligrams prescribed one tablet daily for chronic hepatitis B. 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 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.Your medical records show your doctor prescribed Vemlidy to treat your condition. Medicare approved compendia does support the use of this drug for your diagnosis. However, 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 Vemlidy.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tacrolimus 0.5 milligram capsules prescribed as directed following a kidney transplant. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received 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. We determined that the drug is not eligible for Part B coverage. Medicare enrollment records show the enrollee was entitled to Medicare Part A coverage on June 1, 2018. The documentation submitted states the enrollee received a kidney transplant on February 10, 2017. The enrollee was not eligible for Medicare at the time of the transplant. Therefore, the drug can be considered for payment under the Part D benefit. The prescriber statement shows the doctor prescribed Tacrolimus to provide immunosuppression following a kidney transplant. The Medicare approved compendia do support the use of this drug to prevent kidney transplant rejection. The documentation shows the enrollee has satisfied the plans coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Tacrolimus. Tacrolimus is eligible for Part D coverage and is being utilized for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Pomalyst 3 milligrams prescribed for multiple myeloma. The Part D Plan denied your request for a tiering exception because the provider did not provide a supporting statement documenting that all other drugs in the lower cost-sharing tier for the treatment of the same condition would not be as effective as the drug in the higher 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. Your physician submitted a supporting statement. The records show the physician had prescribed Pomalyst to treat your multiple myeloma. Pomalyst 3 milligrams is a brand drug on Tier 3 of the plans formulary. The prescriber statement shows Thalomid was not tried as it is not indicated with triplet therapy and can exacerbate neuropathy. The plans formulary includes brand Thalomid on Tier 2. Your doctor said you cannot take Thalomid. An oncologist reviewed your appeal and determined that the plan is required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Suboxone (Buprenorphine/Naloxone) 8-2 milligram sublingual film prescribed daily for low back pain. The Part D plan denied your request for a tiering exception because Suboxone is a brand name Tier 4 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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. The plan shows Suboxone is a brand name Tier 4 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sucralfate 1 gram/10 milliliter suspension prescribed for esophagitis. 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. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. The supporting statement did not indicate all formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate 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 Sucralfate suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets prescribed twice daily for paroxysmal atrial fibrillation. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Eliquis is a brand drug on Tier 2 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 this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nicotine 7 milligram/24 hour patches. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Nicotine because it was a nonprescription 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 payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hizentra 4 gram/20 milliliter intravenous solution prescribed for common variable immune deficiency. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows your doctor prescribed the medication for intravenous immunoglobulin therapy in the home. This drug is eligible for coverage under Medicare Part B. Medicare Part D does not cover home therapy of intravenous immunoglobulin.We determined that the plan is not required to cover Hizentra solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 145 microgram capsule. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Linzess 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. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Invega Sustenna 117 milligrams/0.75 milliliter syringe prescribed as directed for schizophrenia. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Invega Sustenna 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. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Multaq 400 milligram tablet prescribed two times daily 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 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.Multaq 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 Modafinil 200 milligrams tablets to treat Fatigue related to Multiple sclerosis.   The Part D plan denied the request.  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 Medicare approved compendia DrugDex states:  'Interestingly, in a 9-week, phase 2, single-blind, 2-center, pilot study (n=72), 2 weeks of modafinil 200 mg daily significantly improved FSS scores compared with placebo in patients with MS.'  Therefore the drug is being prescribed for a medically accepted indication.  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 Reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pulmozyme 1 milligram/milliliter solution to reduce mucous viscosity of airway secretions in a ventilator dependent enrollee with chronic respiratory insufficiency and cerebral palsy.  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 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 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 this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epclusa 400-100 milligram tablet prescribed as directed for chronic viral hepatitis C. 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. Your medical records show you were prescribed Epclusa for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has been met. 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 Epclusa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anastrozole 1 milligram prescribed for cancer. You are requesting reimbursement for the additional 5 tablets filled on December 6, 2020. We received a reconsideration request.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. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. 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, documentation was provided showing that this claim was covered by the plan at the time of purchase and you were reimbursed based on the contracted price for the prescription. We determined the plan is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colchicine 0.6 milligram capsules. The Part D plan denied the request. 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 submitted was insufficient as there were no medical records with a diagnosis. It cannot be determined if the requested drug is medically indicated for the enrollees condition.   Our physician reviewers opinion is that the plan is not required to cover Colchicine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tymlos solution pen-injector 80 micrograms to treat age-related osteoporosis without current pathological fracture. 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. 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. 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Tymlos. A physician reviewed your appeal and determined that the plan is not required to cover Tymlos because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Xeljanz 5 milligram tablets to be taken twice daily. The Part D plan denied the request stating that the medication was prescribed for a non-medically accepted indication. 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 indicates Xeljanz has been prescribed to treat the enrollees dermatomyositis. 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 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 Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Sodium 360 milligram prescribed one tablet a day for post-kidney transplant. The Part D plan was unable to make a timely decision. 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. We determined that the drug is eligible for Part B coverage. The beneficiary had a Medicare-covered transplant on April 12, 2009. Therefore, the drug can be considered for payment under the Part B benefit.We determined that the plan is not required to cover Mycophenolate Sodium.