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

You requested Nulojix 250 milligram vial prescribed to prevent transplant rejection. 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 the enrollee had a liver transplant on April 8, 2019. According to Medicare enrollment records, the enrollee was entitled to Medicare Part A coverage at the time of the transplant. Therefore, the transplant is considered a Medicare covered transplant and Nulojix is eligible for coverage under Medicare Part B. Medicare Part B covers prescription drugs used in immunosuppressive therapy furnished to an enrollee who has received an organ transplant. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. We determined that the Medicare Part D plan is not required to cover Nulojix. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% Patch prescribed once daily to treat low back pain. 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 Lidocaine 5% Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Livalo 1 milligram to treat the enrollees condition. 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.This drug is being provided by the 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 Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Phenytoin sodium extended 100 milligram capsules prescribed for epilepsy. 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. Medicare rules state that for prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must be for treatment of a condition that is completely unrelated to the terminal condition(s) or related conditions for which hospice coverage is being provided. The record shows Phenytoin is being used for treatment of a condition that is related to hospice. However, your drug appears to be eligible for Part A coverage. We determined that the Part D plan is not required to cover the Phenytoin. Please submit your request to Medicare Part A. 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 Opsumit 10 milligram tablet to treat the enrollees condition. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rinvoq ER 15 milligram tablets for atopic dermatitis. 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 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. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Pyridostigmine Bromide 60 milligrams per 5 milliliter syrup prescribed daily for dyskinesia of esophagus, gastroesophageal reflux disease, and dysphagia. 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 Pyridostigmine Bromide for dyskinesia of esophagus, gastroesophageal reflux disease, and dysphagia. In review of the Medicare approved compendia, dyskinesia of esophagus, gastroesophageal reflux disease, and dysphagia are not medically accepted indications for Pyridostigmine Bromide. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Pyridostigmine Bromide at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Opsumit 10 milligram tablets prescribed daily for pulmonary arterial hypertension. 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. This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that a tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Codeine sulfate 30 milligram tablet prescribed as directed for irritable bowel syndrome. 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 information submitted at the reconsideration level. The record shows you were prescribed Codeine sulfate for 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 Codeine sulfate because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Levetircetam 750 milligram tablet prescribed for complex partial seizure 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 systems and reviewed the enrollment data available. The record shows Levetircetam 750 milligram tablet is prescribed to treat complex partial seizure disorder with cerebral meningioma. Medicare records indicate that the enrollee is currently in hospice for malignant neoplasm of unspecified part of unspecified bronchus or lung (C34.90). The provider has indicated that the medication at issue is used to treat a condition related to the terminal illness. Therefore, this drug is eligible for Medicare Part A coverage, and cannot be covered under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the Levetircetam 750 milligram tablet.
Appeal type: Prescription Drug
Decision: Favorable

You requested Ofev 150 milligram capsules prescribed twice daily for pulmonary fibrosis. 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 reviewed your appeal carefully. We reviewed all documentation available.Your medical records show your doctor prescribed Ofev to treat your pulmonary fibrosis. The Medicare approved compendia supports the use of this drug for your condition. The plan's coverage criteria has also been satisfied. The prescriber submitted a high-resolution computed tomography result that supports the presence of lung fibrosis and the submitted diagnosis of pulmonary fibrosis.A physician reviewed your appeal and determined that the plan is required to cover Ofev in a recurring 30-day supply.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Privigen 10% injection prescribed daily for systemic sclerosis, unspecified. The Part D plan denied your request because the requested 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 Privigen was prescribed to treat systemic sclerosis. However, the Medicare approved compendia do not support the use of this drug for this condition. As such, 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.A physician reviewed your appeal and determined that the plan is not required to cover Privigen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vancomycin 250 milligrams /5 milliliter oral solution prescribed three time daily for primary sclerosing cholangitis. 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. 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 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 Vancomycin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tirosint 75 microgram capsule prescribed as directed to treat thyroid cancer. The Part D plan denied the 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 records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover the Tirosint.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica 50 milligram tablets prescribed for your seizures. The Part D plan denied your request. The requested drug is not on the plans formulary. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read 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 not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Lyrica.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide 9 milligram extended release tablets for microscopic cholangitis/collagenous colitis. 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 microscopic cholangitis /collagenous colitis. However, you do not satisfy the plan's prior authorization coverage criteria. The physician stated Mesalamine had not been tried and failed.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 a tier exception for Restasis 0.05 percent ophthalmic emulsion prescribed for dry eye syndrome. The Part D plan denied your request for a tiering exception because Restasis 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 Restasis 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

At issue is Nuedexta 20-milligram/10-milligram capsule to treat pseudobulbar affect with vascular dementia. The Part D plan denied the 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. The prescriber has not sufficiently addressed the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epclusa 400-100 milligram tablet to treat the enrollees condition. The Part D plan denied the 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. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Chantix 1 milligram tablets prescribed for smoking cessation. The Part D plan denied your request for a tiering exception because Chantix 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 Chantix is a brand name Tier 3 drug. 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.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Zarxio 480 micrograms/0.8 milliliter to treat soft tissue sarcoma. 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.This drug is being prescribed for prophylaxis of febrile neutropenia, in non-myeloid malignancies following myelosuppressive chemotherapy and is a medically accepted indication. The combination of chemotherapy drugs include doxorubicin plus ifosfamide for the enrollee's soft tissue sarcoma with metastases. This combination of chemotherapeutic agents is high risk for the development of febrile neutropenia. The documentation includes clinical notes that satisfied the plan's coverage criteria.  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 Alrex 0.2% ophthalmic suspension drops to treat Meibomian gland dysfunction.  The Part D plan denied the request stating that the mediation was not on formulary, and formulary exception criteria 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 use of the requested drug, as prescribed, 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, as ordered, is not being used for a medically accepted indication. The requested drug is not eligible for coverage under Medicare Part D..
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate mofetil 250 milligram capsules for a 90 day supply prescribed for kidney transplant rejection. 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 the enrollee had a kidney transplant on July 8, 2005. According to Medicare enrollment records, the enrollee was entitled to Medicare Part A coverage at the time of the transplant. Therefore, the transplant is considered a Medicare covered transplant and Mycophenolate mofetil is eligible for coverage under Medicare Part B. Medicare Part B covers prescription drugs used in immunosuppressive therapy furnished to an enrollee who has received an organ transplant. We determined that the Medicare Part D plan is not required to cover Mycophenolate mofetil. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humira 40 milligram for Behcets disease. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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 Behcets disease. The use of the requested drug to treat the provided diagnosis is an off-label use. You do not satisfy the plan's prior authorization coverage criteria. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide 0.5 milligram/2 milliliter ampul prescribed for chronic obstructive pulmonary disease. 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 Budesonide is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Budesonide. Please submit your 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.