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

At issue is Xiidra 5% eye drops prescribed for dry eyes. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. The supporting statement did not indicate 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 Xiidra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ventolin HFA 90 microgram inhaler prescribed as directed for chronic obstructive pulmonary disease. 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. Ventolin HFA 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. 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 Sivextro 200 milligram tablets prescribed daily for a pulmonary mycobacterial infection. The Part D plan denied your request because the Food and Drug Administration has not approved this drug for your diagnosis. 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 Sivextro to treat your pulmonary mycobacterial infection. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees condition. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined  that the plan is not required to cover Sivextro. A Part D drug must be prescribed for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3 % patch to treat acute back pain due to minor strain.   The Part D plan denied the request. The requested drug is not on the plans formulary. 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 prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tobramycin 300 milligram/5 milliliter nebulizer solution prescribed for pseudomonas infection following a lung transplant. 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 information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Tobramycin for a pseudomonas infection following a lung transplant. 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 Aranesp 500 micrograms/milliliter subcutaneous injection prescribed as directed. 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. The prescriber states the drug is being prescribed for myelodysplastic syndrome and the enrollee is not on dialysis. However, the prescriber has not submitted medical records to support these statements. The Medicare approved compendia show Aranesp is also indicated for anemia of chronic renal failure (end-stage renal disease). There is insufficient documentation to show that this drug is not eligible for coverage under Medicare Part B. End-stage renal disease related drugs are eligible for coverage by Medicare Part B in the bundled prospective payment to the dialysis facility. There is also insufficient documentation to support that the drug is instead eligible coverage by Medicare Part D.We determined that the plan is not required to cover Aranesp.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Idhifa 100 milligram tablets prescribed daily for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for 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.Idhifa is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier 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: Favorable

At issue is Tacrolimus one-milligram capsule prescribed daily 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. Your records show your doctor prescribed Tacrolimus to prevent rejection following a kidney transplant. The Medicare approved compendia support the use of this drug for your condition. Medicare records support the transplant was not covered by Medicare. Therefore, the Part D plan is required to cover the Tacrolimus.  A physician reviewed your appeal and determined that the plan is required to cover Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Abirateron Acetate 250 milligram tablet prescribed to treat the enrollees condition. The Part D plan denied your request for a tiering exception because the requested drug is in the highest specialty tier and the plan does not allow drugs in this tier at a lower cost-share. 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. Abiraterone Acetate is a generic drug on Tier 5 of the plans formulary. Abiraterone Acetate is on the specialty tier of 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 Abiraterone at a lower cost-share.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Telmisartan-Hydrochlorothiazide 80 milligram-12.5 milligram tablet to treat hypertension. 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 prescriber has not indicated that alternatives required by the plan have been tried and failed or why the plans required step therapy drugs would likely not be as effective as the requested drug. Our physician reviewer's opinion is that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyanocobalamin 1000 microgram/milliliter solution prescribed for vitamin B12 deficiency anemia. The Part D plan denied your request because prescription vitamin and mineral products do not meet the definition of Part D drugs. 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 Cyanocobalamin 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. 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 Hyoscyamine sulfate .125 milligram tablets prescribed for unknown diagnosis. The plan denied your request because Hyoscyamine sulfate is excluded from coverage under Part D. 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 record shows Hyoscyamine is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover Hyoscyamine. 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

You requested First-Lansoprazole 3 milligram/milliliter powder suspension prescribed for gastroesophageal reflux disease without esophagitis. The Part D plan denied your request because the drug at issue was not Food and Drug Administration approved. 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 physician prescribed First-Lansoprazole for gastroesophageal reflux disease without esophagitis. The drug at issue is not Food and Drug Administration approved because of the use as a bulk powder. Therefore, the drug cannot be considered a Part D benefit.We determined that the plan is not required to cover the First-Lansoprazole.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trokendi XR 50 milligram capsules prescribed for an enrollee with chronic intractable migraines. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The physician states the enrollee has failed treatment with one other medication. However, the documentation from the physician does not show why the enrollee cannot take other drugs on the plans formulary for their 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 Ambisome 50 milligram vial prescribed for use with a nebulizer in the home. 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. The record shows Ambisome 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 Ambisome. 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 Hydrocodone-Acetaminophen 10-325 milligram oral tablet. 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.Hydrocodone-Acetaminophen 10-325 milligram oral tablet is a generic drug on Tier 3 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 a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pentasa 500 milligram capsules prescribed twice daily for ulcerative colitis. 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. Pentasa 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: Favorable

At issue is Lynparza 150 milligram tablets prescribed as directed for an enrollee with metastatic non-small cell lung cancer. 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. The documentation shows the doctor prescribed Lynparza to treat metastatic non-small cell lung cancer. The enrollee was previously treated with Carboplatin, Alimta, and Keytruda. Following disease progression, the enrollee was treated with Ramucirumab and Docataxel. However, the enrollees disease progressed further. The enrollee underwent Guardant 360 testing, which identified an ATM mutation. The National Comprehensive Cancer Network guidelines for non-small lung cancer indicate molecular testing should be conducted as part of broad molecular profiling with the goal of identifying rare driver mutations for which effective drugs may be available. The Guardant 360 test results recommend Lynparza as a targeted treatment for this enrollee. The National Comprehensive Cancer Network guidelines for non-small lung cancer also indicate broad molecular profiling is a key component of the improvement of care in patients with non-small cell lung cancer. As such, the National Comprehensive Cancer Network endorses that rare driver mutations be investigated and treated if targeted treatment is available. The Medicare approved compendia do support the off-label use of this drug for the enrollees condition. In this enrollee, who has experienced disease progression despite chemotherapy and immunotherapy, targeting the ATM mutation with a well-tolerated oral drug would be the next step in the enrollees care. An exception to the plans coverage criteria is medically necessary for this enrollee. A physician reviewed your appeal and determined that the plan is required to cover Lynparza.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Anoro Ellipta 62.5-25 microgram inhaler prescribed for the enrollees 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. The plan further denied coverage as a quantity limit exception could not be 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 records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of chronic obstructive pulmonary disease. The plan indicated the enrollee met prior authorization coverage criteria, and the drug was billed for a quantity outside of quantity limit criteria. The prescriber submitted a statement to indicate a request for one inhaler per 30 days or three per 90 days. The prescriber did not request a quantity greater than the plan's quantity limit criteria.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Imbruvica 280 milligrams to be given daily for cold agglutinin mediated hemolytic anemia. The Part D plan denied the drug because it was not medically necessary. The plan requires prior approval before covering some drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level.Imbruvica is being requested to treat cold agglutinin mediated hemolytic anemia. The Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover the Imbruvica.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Voriconazole 200 milligram tablet prescribed twice daily for post lung transplant prophylaxis treatment against aspergillosis. The Part D plan denied your request because the diagnosis provided does not meet the requirements of a Food and Drug Administration 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 records show your doctor prescribed Voriconazole for prophylaxis treatment after your lung transplant on February 27, 2021. Your doctor has determined that you would benefit from this treatment. The Medicare approved compendium, Microdex, supports the Food and Drug Administration has recommended the drug for your condition stating immediate post-transplant prophylaxis for a minimum of 4 months against aspergillosis. The use of Voriconazole resulted in a lower rate of invasive aspergillosis at one-year post lung-transplantation. A physician reviewed your appeal and determined that the plan is required to cover Voriconazole because the Food and Drug Administration has recommended the use of this drug for prophylaxis treatment after lung transplantation.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dalfampridien 10 milligram ER tablets prescribed for multiple sclerosis. 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. The documentation supports the drug was prescribed for the enrollees diagnosis of multiple sclerosis. The Medicare approved compendia designate this drug as an orphan drug for the treatment of multiple sclerosis related symptoms. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.