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

You requested Nuedexta 20/10 milligrams prescribed three times daily for pseudobulbar affect related to amyotrophic lateral sclerosis. The Part D plan denied your request because the prior authorization criteria were not met. We received a standard reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We asked the prescriber to send us medical records and a prescriber statement to show the need for this medication. We received the documentation and included it in our review.The medical records show the doctor prescribed Nuedexta to treat pseudobulbar affect related to amyotrophic lateral sclerosis. The Medicare approved compendium does support the use of this drug for this condition. The medical records submitted also show the enrollee started this drug two times a day in 2018. The enrollee continued to experience involuntary outbursts of laughing and/or crying when only taking this drug twice daily which resulted in isolation. The prescriber statement indicates the enrollee has a covered diagnosis and meets the plans prior authorization criteria. Therefore, the drug can be considered for payment under the Part D benefit.We determined that the plan is required to cover the Nuedexta. The Medicare rules above have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xgeva Solution 120 milligrams/1.7 milliliters injection prescribed once per month for prostate cancer. 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 Xgeva Solution is being prescribed to the enrollee for the treatment of prostate cancer. The documentation provided shows the drug was initially supplied by the prescriber and administered to the enrollee in the prescribers office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. No additional documentation was requested from the prescriber. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Xgeva Solution. 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: Favorable

At issue is Quetiapine Fumarate Extended Release 150 mg daily to treat Generalized Anxiety disorder and Major Depressive disorder. 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 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 has indicated why one required formulary alternative, Apiprazole, would likely not be as effective as the requested drug for the enrollee, and/or would likely cause adverse reaction(s) or other harm to the enrollee. The diagnosis provided is a medically accepted indication, and the extended release version is the only formulation recommended in the compendia. Therefore, an exception to the plans formulary coverage criteria is medically necessary. A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Trikafta 150 milligrams prescribed daily for cystic fibrosis. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Trikafta 150 milligrams daily for cystic fibrosis. The Medicare approved compendia support the use of this drug for your condition. Therefore, the drug can be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is required to cover Trikafta 150 milligrams daily because it was prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Favorable

You requested coverage for Temazepam 30 milligram capsules prescribed daily. The Part D plan denied your request because no diagnosis was submitted and it could not be determined if the medication was 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 Temazepam for insomnia. Your physician indicated the benefits outweighed the risks for this drug.In review of the Medicare approved compendia, insomnia is a medically accepted indication for Temazepam. Therefore, it does meet the definition of a Part D drug. The plan is required to cover the Temazepam at issue.
Appeal type: Prescription Drug
Decision: Favorable

You requested Clobazam 10 milligram tablets prescribed for intractable absence epilepsy. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed the requested drug to treat intractable absence epilepsy. The Medicare approved compendia contain a citation to support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

You requested Cyclobenzaprine five milligram tablets two times daily as needed for acute muscle spasms. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed the requested drug to treat acute muscle spasms. The Medicare approved compendia contain a citation that support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is required to cover Cyclobenzaprine.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tadalafil 5 milligrams to treat benign prostate hyperplasia. The Part D Plan denied the request because medical necessity was not established. 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 enrollee satisfies the Plans coverage criteria per office note of January 22, 2021. A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Methadone 10 milligrams prescribed four tablets three times daily for low back pain with sciatica. The Part D plan denied your request. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding the your condition. We also asked for medical records or other documentation to show why this amount of the medication was needed. We received the documentation and included it in our review.The medical records show Methadone was ordered to treat your low back pain. The prescriber statement indicates you require around the clock dosing and have been on the same dose since 2008. An exception to the quantity limit criteria was met. Therefore, the plan is required to cover the requested quantity of Methadone 360 tablets per 30 days.A physician reviewed your appeal and determined that the plan is required to cover the Methadone.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Aripiprazole 5 milligram tablets prescribed for major depressive disorder. The Part D plan denied the request due to the original condition reported, adjustment disorder with mixed anxiety and depressed mood, was not a medically accepted indication for the drug. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The prescriber indicated that the enrollees diagnosis is major depressive disorder and the enrollee will be taking this drug along with an antidepressant. Medicare approved compendia supports the use of the requested drug, as prescribed, for the treatment of major depressive disorder. A physician reviewed your appeal and determined that the plan is required to cover Aripiprazole.
Appeal type: Prescription Drug
Decision: Favorable

You requested Dupixent 300 milligrams/2 milliliter injection pen prescribed for bullous pemphigoid. The Part D plan denied your request because the drug was not prescribed for a 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. Your medical records show your doctor prescribed the requested drug to treat bullous pemphigoid. The Medicare approved compendium indicates the drug at issue is labelled an orphan drug to treat your condition. A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Magnesium oxide 400 milligram tablets prescribed daily. The Part D plan denied the request because drug is excluded from coverage. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.This drug is not eligible for coverage under Medicare Part D. Magnesium oxide is an excluded drug because it considered a vitamin or mineral product. We determined that the plan is not required to cover magnesium oxide.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Otezla 30 milligrams prescribed twice daily for moderate to severe plaque psoriasis for an enrollee that is a candidate for phototherapy. 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. You submitted a supporting statement and medical records. The medical records show you prescribed Otezla to treat the enrollees moderate to severe plaque psoriasis. Medicare approved compendia support the use of the requested drug for this condition.The records show that the enrollee cannot take other drugs on the plans formulary for their condition. Specifically, the medical records indicate the enrollee has multiple sclerosis. It is noted that presribers should use caution in considering tumor necrosis factor blockers, such as Enbrel or Humira, for enrollees with multiple sclerosis. In addition, the medical records submitted support the enrollees diagnosis of rheumatoid arthritis, which is being treated with Orencia. Concomitant use of Orencia with other immunosuppressive such as biologic disease-modifying antirheumatic drugs is not recommended. Cosentyx, Enbrel, and Humira are considered biologic disease-modifying antirheumatic drugs. Otezla is not a biologic and therefore is considered appropriate to treat the enrollees moderate to severe plaque psoriasis. A physician reviewed your appeal and determined that the plan is required to cover Otezla.
Appeal type: At-Risk Determination
Decision: Partially Favorable

At issue is Eszopiclone 3 milligram tablet prescribed for unknown diagnosis. The documentation shows Eszopiclone is a non-formulary drug on the enrollees plan. However, a formulary exception was approved for dates of service January 1, 2020 through December 31, 2020. The enrollee is requesting reimbursement for the Eszopiclone filled on April 15, 2020, May 14, 2020, June 14, 2020, July 13, 2020, August 15, 2020 and September 16, 2020. We received an auto-forwarded request from the plan to reconsider the appeal.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. No additional documentation was requested from the enrollee.The record shows the enrollee purchased Eszopiclone on April 15, 2020, May 14, 2020, June 14, 2020, July 13, 2020, and August 15, 2020 at the full price from a preferred retail pharmacy. 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. A request for reimbursement was submitted to the plan. In this case, documentation was provided showing that these dates of service were covered by the plan at the time of purchase. We determined that the plan is required to reimburse the enrollee for his share of the cost for Eszopiclone for dates of service April 15, 2020, May 14, 2020, June 14, 2020, July 13, 2020, and August 15, 2020. The record shows the plan paid its share of the cost for the Eszopiclone for date of service September 16, 2020 and the enrollee was responsible for the copay. Therefore, this date of service has already been paid and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Favorable

You requested Calcitriol 0.25 microgram capsule prescribed daily for hyperparathyroidism after kidney transplant. The Part D plan denied your request because the requested drug may be eligible for coverage under Medicare Parts A or B. 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 medical records show your doctor prescribed Calcitriol to treat your hyperparathyroidism. The medical records show that you had a kidney transplant on January 25, 2021, and were not on dialysis. The laboratory report shows that your parathyroid level was elevated at 653.6 pg/ml on January 26, 2021. The Medicare approved compendia supports the use of this drug for your condition. The Calcitriol is not eligible for coverage under Medicare Parts A or B. Therefore, coverage can be allowed for the drug under Part D.  A physician reviewed your appeal and determined that the plan is required to cover Calcitriol.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mycophenolic Acid 180 milligram tablets prescribed daily following a kidney and liver 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 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 records show your doctor prescribed Mycophenolic Acid to prevent rejection following a kidney and liver transplant. The Medicare approved compendia support the use of this drug for your condition. Based on the information provided, the drug is not eligible for Part B coverage.  Therefore, the drug is eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is required to cover Mycophenolic Acid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dextraoamphetamine/amphetamine XR 5 milligrams prescribed daily for excessive fatigue/hypersomnolence. 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Dextraoamphetamine/amphetamine XR 5 milligrams daily to treat your excessive fatigue/hypersomnolence. The enrollee's primary diagnosis in the medical records submitted indicate the enrollee has multiple sclerosis. 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 Dextraoamphetamine/amphetamine XR 5 milligrams because your condition is not a medically accepted indication for this drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mycophenolate mofetil 250 milligram tablets to treat renal transplantation immunosupression. 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 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 also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug would be eligible for coverage under Part D. There is no information in the Medicare Database that indicates you had a covered transplant, paid for by Medicare. This drug is on the plans formulary and being used for a medically accepted indication of status post renal transplantation.A physician reviewed the appeal and determined that the requested drug should be covered by the Part D plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prenatal-U Vitamins 106.5/1 milligram capsule prescribed twice daily for vitamin supplementation.   The Part D plan denied the request as an excluded drug in the Medicare Part D program.  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.For the drug at issue to be covered under Medicare Part D, the manufacturer must participate in the Medicare Coverage Gap Discount Program. This manufacturer is not participating in the program, therefore the drug is excluded from Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amlodipine Besylate 5 milligrams as directed. The Part D plan denied the tiering exception request stating that the case did not include the 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 asked the prescriber to send us information about the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why similar medications on the lower tiers would not work. However, we did not receive the documentation.The record does not include the enrollees diagnosis to support a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Amlodipine Besylate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol Succinate 50 milligrams as directed. The Part D plan denied the tiering exception request stating that the case did not include the 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 asked the prescriber to send us information about the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why similar medications on the lower tiers would not work. However, we did not receive the documentation.The record does not include the enrollees diagnosis to support a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Metoprolol Succinate.