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

At issue is Piqray 300 milligram tablet to treat metastatic breast cancer, hormone receptor-positive, HER2-negative disease, PIK3CA-mutated, not in combination with fulvestrant. 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 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition,
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyanocobalamin 1000 micrograms per milliliter prescribed daily for vitamin B12 deficiency anemia. The Part D plan denied your request because the drug is excluded from Part D coverage. We received an expedited reconsideration request.We performed and 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 determined that the plan is not required to cover Cyanocobalamin because vitamins and minerals are excluded from coverage. The enrollees plan does not offer additional coverage for this drug. If drugs that are excluded are purchased, the enrollee must pay for it. This decision does not address the medical necessity 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 Mycophenolate 250 milligram tablets to prevent rejection after lung transplantation.  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 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 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 requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mycophenolate Mofetil 500 milligrams twice daily for treatment after 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. The medication requested is for a medically accepted indication. It is a formulary medication. It is subject to prior authorization, to determine whether coverage is provided under the Part D drug program. Transplants that were not paid for by Medicare receive this medication under Part D.  Based on the best information available, including the Health Insurance Master Record, your transplant was not paid for by Medicare. A physician reviewed your appeal and determined that the requested drug is covered under Part D.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Prednisone 5 milligrams daily for treatment after 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. The medication requested is for a medically accepted indication. It is a formulary medication. It is subject to prior authorization, to determine whether coverage is provided under the Part D drug program. Transplants that were not paid for by Medicare receive this medication under Part D. Based on the best information available, including the Health Insurance Master Record, your transplant was not paid for by Medicare. A physician reviewed your appeal and determined that the requested drug is covered under Part D.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tacrolimus 1 milligram twice daily for treatment after 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. The medication requested is for a medically accepted indication. It is a formulary medication. It is subject to prior authorization, to determine whether coverage is provided under the Part D drug program. Transplants that were not paid for by Medicare receive this medication under Part D. Based on the best information available, including the Health Insurance Master Record, your transplant was not paid for by Medicare. A physician reviewed your appeal and determined that the requested drug is covered under Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Pradaxa 150 milligrams daily to treat atrial fibrillation. 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.Pradaxa is a brand drug on Tier 4 of the plans formulary. The prescriber has not indicated that the enrollee has tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective for the enrollee as the requested drug. 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

At issue is Vascepa 1 gram prescribed twice a day for coronary artery disease with mixed hyperlipidemia. The Part D Plan denied your request because there were no lower tier alternatives for the enrollees condition. 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 medical record shows Vascepa is being prescribed for coronary artery disease with mixed hyperlipidemia. The Medicare approved compendia supports the use of the requested drug for the enrollees condition. Vascepa is a brand name drug on Tier 3 of your plan's formulary. However, there are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Vascepa 1 gram because there are no lower tier alternatives.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathioprine 50 milligram tablet to prevent rejection in a heart transplant enrollee. 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 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 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 requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xtandi 40 milligram capsules prescribed as directed for ovarian cancer. 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. The documentation shows the doctor prescriber Xtandi to treat a recurrent steroid cell tumor of the ovary. However, the Medicare approved compendia do not support the use of Xtandi for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Xtandi.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lanoxin 62.5 microgram tablets prescribed for chronic diastolic heart failure. You asked the Part D plan to provide 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. We also researched Medicare systems and reviewed the enrollment data available.The records show Lanoxin is being prescribed for chronic diastolic heart failure. The Medicare approved compendia support the use of the requested drug for your condition. Lanoxin is a brand name drug that is on Tier 4 of your plan's formulary. There are no brand name 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.The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit. Therefore, the plan is not required to grant a tiering exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligrams prescribed as directed for eosinophilic asthma. The Part D plan denied your request because the drug you requested is not included on your plans formulary. We received an expedited reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows that your doctor prescribed Dupixent to treat your asthma. The Medicare approved compendium supports the use of this drug to treat your condition. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine hydrochloride 2 milligrams sublingual tablets prescribed as directed for chronic pain syndrome and irritable bowel syndrome. The Part D plan denied the 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. The record shows you were prescribed Buprenorphine hydrochloride sublingual tables as directed for chronic pain syndrome and irritable bowel syndrome. However, the Medicare approved compendia do not support the use of this drug for your 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 the Buprenorphine hydrochloride sublingual tablets because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You prescribed Pyridostigmine Bromide 30 milligrams for inflammatory and autonomic peripheral neuropathy. 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. The submitted documentation indicates the drug was prescribed for inflammatory peripheral neuropathy and small fiber neuropathy. The Medicare approved compendia do not support the use of this drug for the enrollees 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 Prograf 0.5 milligram prescribed as directed following a 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 medical records show your doctor prescribed Prograf 0.5 milligram after a liver transplant. The record shows that you received a kidney transplant on January 26, 2011. According to Medicare enrollment records, you were entitled to Medicare Part A coverage on July 1, 2009. Medicare law excludes coverage for any drug under the Part D program for which payment would be available under Parts A or B. Coverage is available under Medicare Part B for prescription drugs used in immunosuppressive therapy furnished to an enrollee that was covered under Medicare Part A at the time of the transplant. You were covered under Medicare Part A at the time of the transplant. 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 Prograf 0.5 milligram because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit.You may wish to submit a request for Prograf 0.5 milligram to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 5 milligrams to treat nausea and vomiting associated with cancer chemotherapy in an enrollee with prostate cancer.   The Part D plan denied the request because it does not meet the prior authorization requirements. Therefore, the request for a higher quantity limit cannot be 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 enrollee does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plans coverage criteria and has not indicated why all alternatives required by the Plan would likely cause harm or not be as effective for the enrollee as the requested drug.  A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xalkori 250 milligrams prescribed twice daily for metastatic castration-resistant prostate cancer. 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Xalkori 250 milligrams twice daily to treat your metastatic castration-resistant prostate cancer. However, the Medicare approved compendia do not support the use of this drug for your 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 Xalkori 250 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Caduet 5-10 milligram tablet to treat your hypertension.   The Part D plan denied your request for a tiering exception because the requested drug cannot be provided 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.This drug is being provided by your plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per the Centers for Medicare and Medicaid Services rules, non-formulary drugs 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: Unfavorable

You requested coverage for Vyvanse 50 milligram capsules prescribed daily for mild cognitive impairment. 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 Vyvanse for mild cognitive impairment.In review of the Medicare approved compendia, mild cognitive impairment is not a medically accepted indication for Vyvanse. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Vyvanse at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You prescribed Temazapan 30 milligram capsules for polycythemia vera. 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. The submitted documentation indicates the drug was prescribed for polycythemia vera. The Medicare approved compendia do not support the use of this drug for the enrollees 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

At issue is Rytary 48.75-195 milligrams four times daily prescribed for Parkinsons disease. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. We received 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.Rytary 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 to treat the same condition. 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

You requested Budesonide 0.5 milligram/2 milliliter nebulizer solution prescribed as directed for chronic obstructive pulmonary disease. 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 medical records show your doctor prescribed Budesonide 0.5 milligram/2 milliliter nebulizer solution to treat your chronic obstructive pulmonary disease. We determined that the drug is not eligible for Part D coverage. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. 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 Budesonide 0.5 milligram/2 milliliter nebulizer solution because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit.You may wish to submit a request for Budesonide 0.5 milligram/2 milliliter nebulizer solution to the Medicare Part B carrier.