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

At issue is Xarelto 20 milligram tablets prescribed for anticoagulation in an enrollee with atrial fibrillation. The Part D plan denied your request for a tiering 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.Xarelto 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.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 Procrit 40,000 units/milliliter subcutaneous injection prescribed for unspecified anemia. 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 documentation shows your doctor prescribed Procrit to treat your unspecified anemia prior to surgery, without plan for auto-transfusion. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz XR 5 milligram tablets prescribed for eczema. 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.The documentation submitted indicates the Xeljanz XR at issue was prescribed for eczema. The Medicare approved compendia do not support the use of the drug at issue for your 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 Humira 40 milligram/0.4 milliliter pen injection prescribed for relapsing polychondritis. 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.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.A physician reviewed your appeal and determined that the plan is not required to cover Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz XR 11 milligram tablet prescribed daily for rheumatoid arthritis. 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 1% topical gel prescribed 100 grams every 13 days for osteoarthritis of the right knee. 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 records submitted at the reconsideration level. Your medical records show your doctor prescribed Diclofenac Sodium 1% topical gel to treat your osteoarthritis of the right knee. Your plan has prior authorization requirements for this drug that must be met 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 Diclofenac Sodium 1% topical gel. The physician has stated there was no reason you could not try non-steroidal anti-inflammatory drugs. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Anoro Ellipta 62.5-25 microgram inhalation powder prescribed for chronic bronchitis. 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. The documentation submitted did not indicate that all the formulary alternatives were tried and would be ineffective.  Therefore, an exception to the Plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine Hydrochloride 8 milligram sublingual tablets prescribed for chronic pain and cervical disc disease. 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.The documentation submitted indicates the Buprenorphine Hydrochloride sublingual tablets at issue were prescribed for chronic pain and cervical disc disease. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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 Albuterol Sulfate 2.5 milligrams per 3 milliliter prescribed one vial via nebulizer every four hours as needed for chronic obstructive pulmonary disease. 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 record shows Albuterol Sulfate 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 Albuterol Sulfate. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Humulin R 500 unit per milliliter concentrated solution prescribed for the treatment of type 2 diabetes mellitus. 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 documentation indicates that the Humulin R solution is going to be administered via an insulin infusion pump. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as insulin infusion pumps. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Coverage under Part D is excluded for any drug for which payment would be available under Part B. We determined that the Medicare Part D plan is not required to cover the requested drug. 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. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 1% ointment prescribed 2-3 times daily for burning mouth syndrome. 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 documentation shows your doctor prescribed Tacrolimus to treat your burning mouth syndrome. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patches prescribed for pain following a total hip arthroplasty. 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.The prescriber submitted a statement to indicate the enrollee has a diagnosis of hip osteoarthritis; however, the medical records submitted do not support the drug was prescribed for this condition. The medical records indicate the enrollee has hip pain following a total hip arthroplasty. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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 Mycophenolate Mofetil 500 milligram tablets prescribed for interstitial lung disease. 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.The documentation submitted indicates the Mycophenolate Mofetil at issue was prescribed for interstitial lung disease. The Medicare approved compendia do not support the use of the drug at issue for your 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 Keytruda prescribed for tongue cancer. 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 drug at issue is an intravenous chemotherapy drug. This is eligible for coverage under Part B. 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: Favorable

You requested Lidocaine-Prilocaine Cream 2.5%-2.5% prescribed for topical local anesthetic to skin to port area 60 minutes prior to chemotherapy. The Part D plan denied the request due to the enrollee is a dialysis patient and payment would be bundled to the dialysis facility.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. In the Reconsideration appeal the prescriber provided medical records and a prescriber statement.  The medical records submitted confirm the enrollee is starting chemotherapy for metastatic colon cancer.   The requested drug is being used prior to chemotherapy to numb the port area prior to access for chemotherapy.  The requested drug is not being used for end stage renal disease.  The records also show that the enrollee has a left upper extremity arteriovenous fistula that is used for hemodialysis.  This is not the area being used for chemotherapy.  The port has been placed in the left internal jugular vein.A physician reviewed your appeal and determined that the plan is required to cover Lidocaine-Prilocaine Cream.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Adempas 0.5 milligram tablets prescribed for chronic thromboembolic pulmonary hypertension (CTEPH), World Health Organization (WHO) Group 4. The Part D plan denied the request for coverage.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. Selective pulmonary angiography and ventilation-perfusion reports are provided and satisfy coverage criteria. Enrollee is classified as WHO functional status III. Provider and enrollee have determined that he is not a surgical candidate for pulmonary endarterectomy, a complex medical intervention.The documentation provided satisfies the plans 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

You requested Buprenorphine Hydrochloride tablet sublingual 2 milligram, a quantity of 90 per 30 days with the diagnoses of rheumatoid arthritis and idiopathic scoliosis, thoracic region. 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 record shows the diagnoses of rheumatoid arthritis and idiopathic scoliosis, thoracic region. The medical record further supports that your doctor prescribed Buprenorphine Hydrochloride tablet(s) sublingual 2 milligram to treat your pain. However, the Medicare approved compendia do not support the use of this specific drug in sublingual tablet form for your condition(s). A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride tablet(s).
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Lantus 100 units/milliliter vial prescribed for the enrollees condition. 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.Lantus is a biologic on Tier 2 of the plans formulary. There are no biologics of the same type on the lower cost sharing tiers. Therefore, this biologic 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 Mycophenolate Mofetil 500 milligram tablets prescribed for hypersensitivity pneumonitis and interstitial lung disease. 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.The documentation submitted indicates the Mycophenolate Mofetil at issue was prescribed for hypersensitivity pneumonitis and interstitial lung disease. The Medicare approved compendia do not support the use of the drug at issue for your 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 Mesalamine 1.2 gram oral tablet prescribed twice daily. The Part D plan denied your request for a tiering 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. Mesalamine is a generic drug on Tier 4 of the plans formulary. There are no medical records to support that all drugs available on lower tiers to treat your condition have been tried or deemed contraindicated. 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: Favorable

At issue is Lenvima 20 milligram daily dose therapeutic pack prescribed for metastatic endometrial cancer. The Part D plan denied the 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. Your medical records show your doctor prescribed Lenvima to be given with Keytruda to treat your metastatic endometrial cancer. An initial diagnosis was stage 3 endometrial carcinoma, status post adjuvant Carbo/Taxol and vaginal brachytherapy. There was progression and molecular profiling showed HER2 mutation. In addition, there was evidence of microsatellite instability intact/mismatch repair proficient status. Herceptin/Taxol was started but there was progression with increased peritoneal disease. Per the Food and Drug Administration, Lenvima can be given with Keytruda for metastatic endometrial cancer that is not microsatellite instability-high or deficient mismatch repair, in combination with Pembrolizumab in patients with disease progression following prior systemic therapy who are not candidates for curative surgery or radiation. In addition, there was extensive liver metastasis and peritoneal disease with ascites so she is not a candidate for surgery or radiation. There was progression on systemic therapy and she does fit all Food and Drug Administration criteria. Per the prior authorization criteria, all compendia/Food and Drug Administration indications are appropriate and the drug is on the plans formulary and the condition of the enrollee is a medically accepted indication for the drug.  A physician reviewed your appeal and determined that the plan is required to cover Lenvima.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lynparza 150 milligram tablets prescribed for metastatic esophageal carcinoma. 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.The submitted documentation indicates your doctor prescribed Lynparza for metastatic esophageal carcinoma. The Medicare approved compendia do not support the use of the drug at issue for your conditions. There are no Medicare approved journal articles to support the use of the drug for your 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 Azor 5-20 milligram oral tablet prescribed daily for hypertension. 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 asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, no medical records were submitted for review to support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Azor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dextroamp-Amphet extended release 20 milligram capsule. At initial determination and redetermination no diagnoses were provided. 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 asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need this medication. We did not receive the documentation requested. Specifically, no medical records were provided for review.In this case, a diagnosis/condition was not given. It could not be determined whether the drug was being prescribed for a medically accepted indication. Therefore, the 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 Dextroamp-Amphet extended release 20 milligram capsule.