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

At issue is Cyclosporine 25 milligram tablets 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 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 Cyclosporine to prevent rejection following a kidney transplant. The Medicare approved compendia support the use of this drug for your condition. Based on the information provided, the drug is eligible for Part B coverage.  Therefore, the drug is not eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is not required to cover Cyclosporine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 30 milligram tablet to treat Hashimoto's thyroiditis. 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.Non Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Enbrel, 50 milligrams per milliliter mini cartridge, prescribed for rheumatoid arthritis. The Part D Plan denied your request for a tiering exception because there were no other similar 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. A physician reviewed your appeal and determined that the plan is not required to cover the Enbrel at a lower cost tier.Enbrel is a biologic drug on Tier 2 of the plans formulary. There are no biologic drugs of the same type on the lower cost sharing tiers. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. Therefore, a tiering exception cannot be granted for  the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cinacalcet Hydrochloride 30 milligram tablets prescribed daily for secondary hyperparathyroidism of renal origin. The Part D plan denied your request to cover the medication under Part D. 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 other information submitted at the reconsideration level.The record shows that your doctor prescribed Cinacalcet Hydrochloride for secondary hyperparathyroidism of renal origin. Records indicate you are on dialysis with an end stage renal disease start date of September 26, 2017, and end date of December 31, 2099. The medication is end stage renal disease related and not covered under Part D.  Therefore, Tacrolimus is covered under Medicare Part B. As such, our decision is that the Part D plan is not required to cover Cinacalcet Hydrochloride. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clonidine hydrochloride ER 0.1 milligram tablets prescribed as directed for attention-deficit/hyperactivity disorder and impulse control disorder in an adult. The Part D plan denied your request because 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. The medical records show the doctor prescribed Clonidine hydrochloride for attention-deficit/hyperactivity disorder and impulse control disorder. However, the Medicare approved compendia do not support the use of this drug for adults with attention-deficit/hyperactivity disorder and impulse control disorder.A physician reviewed your appeal and determined that the plan is not required to cover Clonidine hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zonegran 25 milligram capsules prescribed as directed for dystonic vocal tremor and essential tremor. The Part D plan denied your request because 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. The medical records show the doctor prescribed Zonegran for dystonic vocal tremor and essential tremor. However, 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 Zonegran.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zelnorm 6 milligram tablet prescribed for constipation. The Part D plan denied your request because the drug was excluded from coverage under Medicare Part D because it is a brand drug, and its manufacturer has not signed the Medicare Coverage Gap Discount Agreement. 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 Zelnorm is excluded from coverage under Medicare Part D because it is a brand drug and its manufacturer has not signed the Medicare Coverage Gap Discount Agreement. 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, Alfasigma USA, 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 Zelnorm. 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 Lidocaine 5% patch to treat ankle pain. 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. Relevant medical records were requested with the reconsideration appeal. No medical records were provided. 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

You requested coverage for Oxycontin ER 80 milligram tablets prescribed daily for pancreatitis and lumbar disc herniation. 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 Oxycontin ER for pancreatitis and lumbar disc herniation.In review of the Medicare approved compendia, pancreatitis and lumbar disc herniation are not medically accepted indications for Oxycontin ER as prescribed. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the drug at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Glucagon Emergency Kit 1 milligram for anaphylactic shock, unspecified. The Part D plan denied your request because this drug is not medically accepted for this condition. 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. We also researched Medicare regulations and Medicare approved compendia. 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. The drug is not approved by the food and drug administration to treat the diagnosis submitted. 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 a Glucagon Emergency Kit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Omega-3-acid ethyl esters 1 gram capsules prescribed as directed for mixed hyperlipidemia. The Part D plan denied your request because 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. The medical records show the doctor prescribed Omega-3-acid ethyl esters for mixed hyperlipidemia.  However, 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 Omega-3-acid ethyl esters.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vemlidy 25 milligram tablets prescribed daily for chronic Hepatitis B viral infection. The Part D plan denied coverage because the prior authorization criteria were not met. 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. We also researched Medicare systems and reviewed the enrollment data available.The documentation shows the doctor prescribed Vemlidy to treat chronic Hepatitis B viral infection. The prescriber statement indicates that you do not have compensated liver disease. The Medicare approved compendia do not support the use of this drug for your condition. Additionally, the documentation provided does not show you have satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine, 10-milligram tablet prescribed one nightly for muscle spasms. The Part D plan denied your request because Cyclobenzaprine is not Food and Drug Administration approved for your medical conditions of osteoarthritis multiple joints and insomnia. The Medicare approved compendia supported indications are fibromyalgia and skeletal muscle spasm associated with acute painful musculoskeletal conditions, in which you do not have. Your condition is chronic and, therefore, the clinical circumstances do not meet off-label guideline criteria. We received an expedited reconsideration. 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 medical record shows that your doctor prescribed Cyclobenzaprine for your muscle spasms after fusion of the right ankle. However, your condition is chronic and, therefore, the off-label use of this drug is not approved by the Food and Drug Administration for your condition.A physician reviewed the appeal and determined that the plan is not required to cover the drug because your diagnosis is not covered for the use of this drug per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Propafenone hydrochloride ER 325 milligram capsules prescribed every 12 hours for paroxysmal atrial fibrillation. The Part D Plan denied your request for a tiering exception because the documentation did not support why alternative drugs in a lower tier could not be used for this enrollee. 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. Propafenone hydrochloride ER is a generic drug on Tier 4 of the plans formulary. The doctor submitted a supporting statement. The statement said the enrollee could not tolerate one of the alternative drugs due to dizziness and syncope. The prescriber has not indicated that you have tried all alternatives required by the Plan, or why the Plans lower tiered drugs would likely not be as effective as the requested drug.  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 Colcrys 0.6 milligram tablet to treat gout. 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 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

You requested Tadalafil 5 milligram tablets prescribed as directed for erectile dysfunction. The Part D plan denied your request because drugs being used for the treatment of erectile dysfunction are excluded from coverage by Medicare Part D. 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. We determined that the plan is not required to cover Tadalafil. Drugs prescribed for the treatment of sexual or erectile dysfunction 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

At issue is Basaglar KwikPen 100 units/milliliter prescriber for type II diabetes mellitus. The Part D plan denied coverage because the prior authorization criteria were not met. 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 Basaglar KwikPen to treat type II diabetes mellitus. The Medicare approved compendia do support the use of this drug for the enrollees condition. The plan requires an intolerance or contraindication to an insulin glargine product and two other long-acting insulin products 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 Basaglar KwikPen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lamivudine 100 milligram tablet prescribed daily following a liver transplant. 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. Lamivudine is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type on the lower 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 for the drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Budesonide EC 3 mg Capsule to treat Lymphocytic Colitis.   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 documentation does not satisfy the Plans coverage criteria.  In the Reconsideration appeal the prescriber sent relevant medical records.  The documentation supports the diagnosis of Lymphocytic colitis.  DrugDex, a Medicare approved compendia states, c) In a systematic review and meta-analysis of randomized trials that included patients with lymphocytic colitis (5 trials and 149 patients), and compared medical therapy to either placebo or an active comparator, 88% of patients who received budesonide for induction achieved clinical response (no more than 3 non-watery stools/day or satisfactory control of diarrhea) vs 38% of patients who received placebo (2 studies; 57 patients; RR 2.03, 95% CI 1.25 to 3.33). Histological response occurred in 78% and 33% of patients who received budesonide and placebo, respectively (2 studies; 39 evaluable patients; RR 2.44, 95% CI 1.13 to 5.28). Budesonide was well tolerated in both trials. Evidence was deemed low-quality for all outcomes reported.  The prescriber has indicated why all alternatives required by the Plan would likely not be as effective as the requested drug for you, or would likely cause adverse reaction(s). Therefore, an exception to the Plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Ointment 5% prescribed for pain related to rheumatoid arthritis. The Part D plan denied the request. 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. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia does not support the use of this medication for the diagnoses submitted. Therefore, it is ineligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine Ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entecavir, 0.5 milligram tablets prescribed daily for chronic viral hepatitis B without delta-agent. The Part D Plan denied your request for a tiering exception because the submitted documentation did not explain why the plans alternative drugs in lower tiers would not work just as well. 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. A physician reviewed your appeal and determined that the Entecavir is not eligible for a tiering exception.Entecavir is a generic drug on Tier 4 of the plans formulary. The submitted documentation does not address why the generic drugs of the same type on the lower tiers of the plans formulary have been tried and failed, or are contraindicated. Therefore, the plan cannot grant a tiering exception for the Entecavir at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rasuvo 25 milligram per 0.5-milliliter subcutaneous injection to treat ankylosing spondylitis. 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 Gralise 600 milligram tablets to treat neuropathic pain associated with lumbar stenosis, facet arthropathy, and scoliosis. The Part D plan denied the request stating that the provided diagnosis is not a 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.