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

You requested Zejula 100 milligram capsules prescribed for the maintenance treatment of advanced epithelial ovarian cancer in a complete or partial response to first-line platinum based chemotherapy. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The medical records show you prescribed Zejula 100 milligram capsules for the maintenance treatment of advanced epithelial ovarian cancer in a complete or partial response to first-line platinum based chemotherapy. The Medicare approved compendia do support the use of this drug for this condition. The plan requires a diagnosis of advanced epithelial ovarian cancer, evidence of complete response or partial response to first-line treatment with platinum based chemotherapy, and use of Zejula as monotherapy before they will cover the requested drug. The medical records submitted support a diagnosis of advanced epithelial ovarian cancer, for which the provider wishes to treat with Zejula as monotherapy. In addition, the records now include positron emission tomography scan results from March 29, 2021, which are consistent with an excellent treatment response with no evidence for residual or recurrent malignancy. The documentation provided does show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Zejula 100 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Potassium Citrate- Citric Acid solution prescribed as directed for urinary stones. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We determined that the plan is not required to cover Potassium Citrate-Citric Acid solution because prescription vitamins and minerals 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 Mesalamine suppository prescribed for your ulcerative colitis. 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 reviewed your appeal carefully. We reviewed all documentation available.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 Mesalamine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Xeljanz 10 milligram tablets prescribed for severe alopecia areata. 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 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 Clindamycin Phosphate 1 percent topical solution prescribed for hidradenitis suppurativa.  The Part D plan denied coverage because the off formulary exception rules were not met.  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 record shows you were prescribed Clindamycin Phosphate for hidradenitis suppurativa. In review of the Medicare approved compendia, hidradenitis suppurativa is not a medically accepted indication for Clindamycin Phosphate. 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 drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Anoro Ellipta 62.5-25 microgram inhaler. At initial determination and redetermination the diagnosis of seasonal allergies was given. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. At reconsideration a diagnosis of moderate asthma was given. This is not a medically accepted indication per the Medicare approved compendia. 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 the Anoro Ellipta inhaler.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Combigan 0.2 percent-0.5 percent eye drops prescribed as directed for ocular hypertension. The Part D plan denied your 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. Combigan is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the enrollee's condition. 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 a tiering exception request for Symbicort 160-4.5 micrograms to treat chronic obstructive pulmonary disease. 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.Symbicort is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Evenity 105 milligram/1.17 milliliter injection prescribed for your osteoporosis. 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 documentation supports the drug was prescribed for your diagnosis of osteoporosis. There is support for post-menopausal osteoporosis, long-standing history of steroid use, and fractures. However, there is not evidence of a failure of other drugs for osteoporosis. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem tartrate 10 milligram tablet prescribed as directed to treat insomnia. The Part D plan denied the 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 levelThe medical records show you were prescribed Zolpidem tartrate to treat 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 Zolpidem tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Eliquis 5 milligram tablets prescribed for atrial fibrillation. The Part D plan denied your request for a tiering exception because Eliquis is a brand name Tier 3 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 Eliquis is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels for your condition. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vardenafil Hydrochloride 5 milligram tablets prescribed to treat benign prostatic hyperplasia without lower urinary tract symptoms. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The Medicare approved compendia does not support the use of the drug for your conditionA physician reviewed your appeal and determined that the plan is not required to cover Vardenafil Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dupixent 300 milligram/2 milliliter pen prescribed to treat atopic dermatitis. The Part D plan denied your request for a formulary exception. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The drug requested is not on the plans formulary. The medical records do not specifically address each formulary alternative and why they did not or would not work. A physician reviewed your appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Marinol 2.5 milligram capsules to treat weight loss due to mycobacterium szolgari and anorexia.  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. 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 Marinol for weight loss due to mycobacterium szolgari and anorexia. In review of the Medicare approved compendia, weight loss due to mycobacterium szolgari and anorexia is not a medically accepted indication for Marinol. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Marinol at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets prescribed to treat small intestine bacterial overgrowth. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia does not support the use of the drug for your conditionA physician reviewed your appeal and determined that the plan is not required to cover Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol Capsules 2.5 milligrams prescribed prophylactically to control nausea and vomiting as the enrollee is projected to undergo radiation therapy. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The Medicare approved compendia does not support the use of the drug for your conditionA physician reviewed your appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 5 milligram Capsules prescribed for anorexia and abnormal weight loss. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. This drug is excluded from Medicare Part D drug benefits when used for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Favorable

You requested Tacrolimus 1 milligram capsule prescribed for kidney transplant. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows you received a kidney transplant on August 31, 2000, which was not covered under Medicare Part A. According to Medicare enrollment records, you were not entitled to Medicare Part A coverage at the time of the transplant. Therefore, your transplant is not considered a Medicare covered transplant and Tacrolimus is not eligible under Medicare Part B. Therefore, we determined that the Part D plan is required to cover the Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Trulicity 1.5 milligram/0.5 milliliter pen prescribed for diabetes mellitus. The Part D plan denied your request for a tiering exception because Trulicity is a brand name Tier 3 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 Trulicity is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels for your condition. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zestril 20 milligram tablets prescribed to treat high blood pressure. The Part D plan denied your request for a formulary exception. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The drug requested is not on the plans formulary. The records do not show why the enrollee cannot take all other drugs on the plans formulary for their condition. We requested additional information from the prescriber but did not receive a response. A physician reviewed your appeal and determined that the plan is not required to cover Zestril.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 20-10 milligram Extended Release Capsules prescribed to treat epilepsy unspecified not intractable without status epilepticus. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The Medicare approved compendia does not support the use of the drug for your conditionA physician reviewed your appeal and determined that the plan is not required to cover Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dextroamphetamine Sulfate 5 milligram Extended Release Capsules prescribed to treat Major Depressive Disorder. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The Medicare approved compendia does not support the use of the drug for your conditionA physician reviewed your appeal and determined that the plan is not required to cover Dextroamphetamine Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xadago 100 milligram tablets prescribed twice daily for Parkinsons disease. The Part D plan denied coverage.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 on hand does not include a physician supporting statement. A request for a supporting statement was submitted to your doctor; however, no further documentation was received. The enrollee does not satisfy the plan's step therapy authorization coverage criteria. In addition, your doctor has requested a quantity greater than the plans authorized quantity limits. As the drug cannot be covered, a quantity limit exception cannot be granted.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Brukinsa 80 milligram capsules prescribed to treat Waldenstrom macroglobulinemia.  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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. However, the prescriber provided a peer-reviewed, clinically relevant, article from an approved journal to support this appeal. This Phase III study from the journal Blood, represents the clinical scenario in this enrollee and reports positive results, including fewer serious side effects that this enrollee has experienced. Therefore, the requested drug is prescribed for a medically accepted indication as defined by Medicare.  As such, a Prior Authorization exception request based on medical necessity can be approved. Therefore, the requested drug is eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Favorable

You requested Belbuca 300 microgram film prescribed for unknown diagnosis. The Part D plan approved your request.We received a case to perform 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. The record shows you purchased the Belbuca from a network pharmacy on February 21, 2021. The plan provided documentation showing the drug was approved for coverage beginning February 19, 2021 with no end date. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The documentation submitted includes a receipt showing you paid for the Belbuca. We determined that the plan is required to reimburse you for their share of the cost for the Belbuca.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eletriptan Hydrobromide 40 milligram oral tablet prescribed daily for chronic migraine without aura, intractable, without status migrainosus. The Part D Plan denied your request for a tiering exception. We received an auto-forwarded reconsideration request from the coverage level. 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. Eletriptan Hydrobromide is not a drug that is listed on the plans formulary. Medicare does not allow tiering exceptions for non-formulary drugs.  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.