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

At issue is Symbicort 160-4.5 micrograms/actuation aerosol inhaler prescribed twice daily for asthma. 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 submitted does not include medical records to support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Symbicort.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Oxaydo 7.5 milligram tablets prescribed for chronic pain due to lumbar post-laminectomy syndrome. 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.Oxaydo is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives included in the plan to treat the noted condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz XR 11 milligram tablets. 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 does not contain a supporting statement or medical records to indicate a prescribed diagnosis. A request for a supporting statement and medical records was sent to your doctor; however, no additional documentation was received. As it cannot be determined that the drug was 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 Hetlioz 20 milligram capsules prescribed daily for circadian rhythm sleep disorder, free running type. 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 this medication. We did not receive the documentation requested.The records show Hetlioz is prescribed to treat circadian rhythm sleep disorder, free running type. The Medicare approved compendia do support the use of this drug for this condition. However, the plan requires prior authorization criteria be met before they will cover the drug. The documentation provided does not show you have satisfied the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz 20 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise 600 milligram tablets to treat diabetic peripheral neuropathy.  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.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Afinitor 10 milligram tablets prescribed daily to treat metastatic vaginal melanoma. 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 the doctor prescribed Afinitor to treat metastatic vaginal melanoma. The enrollee has been treated with multiple lines of therapy, including: Opdivo with Yervoy, surgery, radiation, Carboplatin with Taxol and Avastin, as well as Gleevec, and Temodar. FoundationOne testing results showed PTEN and KIT mutations. The prescriber recommends treatment with Afinitor due to the identification of the PTEN mutation. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Afinitor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Voriconazole 200 milligram tablets prescribed twice daily for the prevention of fungal infections. 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 the enrollee has chronic graft versus host disease. The doctor prescribed Voriconazole as an antifungal prophylactic medication. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Voriconazole.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydromet 1.5 milligrams/5 milliliters-5 milligrams/5 milliliters oral syrup prescribed as directed for cough. 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 determined that the plan is not required to cover Hydromet because it was prescribed for the symptomatic relief of cough. Drugs prescribed for symptomatic relief of cough 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 Lansoprazole 30 milligrams oral disintegrating tablet (ODT) prescribed to treat gastroesophageal reflux 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 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

You requested Flector 1.3% topical patch prescribed every 12 hours for chronic back pain related to cervical spondylosis, acquired scoliosis, and spinal stenosis. 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 the doctor prescribed Flector patch to treat chronic back pain related to cervical spondylosis, acquired scoliosis, and spinal stenosis. 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 Flector patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Mycophenolate Mofetil 500 milligram capsules. 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 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 indicates that Mycophenolate Mofetil has been prescribed for vasculitis related to Sjogren's syndrome. However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lumigan 0.01% drops prescribed to treat the enrollee's condition. 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.Lumigan is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for a tiering exception for Xarelto 10 milligram tablets prescribed for atrial fibrillation. 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.Xarelto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Xarelto at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Favorable

You requested Isotretinoin 40 milligram capsules prescribed as directed for dissecting cellulitis of the scalp. 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.At redetermination, diagnoses of dissecting cellulitis of the scalp and cicatricial alopecia were given. Upon reconsideration, a diagnosis of severe acne was provided. Medical record of dermatologist, April 1, 2021, described severe acne unresponsive to oral antibiotics and other topicals, with follow-up signed letter of May 7, 2021, inferring acne conglobata, a very severe form of acne. The requested drug was prescribed for a medically accepted indication. Therefore, the requested drug is eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is required to cover Isotretinoin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise Extended Release 300 milligram tablets prescribed for restless leg 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. Your prescriber indicated that Gralise Extended Release 300 milligram tablets is prescribed to refractory restless leg syndrome. However, the Medicare approved compendia do not support the use of this drug, as prescribed, for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Gralise Extended Release tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Megestrol Acetate 400 milligram/10-milliliter oral suspension prescribed daily for anorexia related to depression and grief with a history of weight loss and diabetes. 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. 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, 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

At issue is Novolog 100 unit/milliliter vial prescribed for diabetes. 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. Novolog 100 unit/milliliter vial is a BRAND drug on Tier 3 of the plans formulary. There are no other BRAND insulin drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Polyethylene Glycol 3350 Powder 17 grams by mouth daily prescribed to treat constipation. The Part D plan denied your request because the requested product is not approved as a drug by the food and drug administration.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. Polyethylene Glycol 3350 Powder was requested by your physician to treat your constipation. It is approved by the food and drug administration in use for constipation. Drugs prescribed that are available Over the Counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to cover Polyethylene Glycol 3350 Powder.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62 percent gel. 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. We also researched Medicare systems and reviewed the enrollment data available.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 this medication. We did not receive the documentation requested.We were unable to obtain medical records from your prescriber. No medical records were provided by the prescriber. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Testosterone 1.62 percent gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Repatha SureClick 140 milligram per milliliter subcutaneous auto injection pen prescribed for coronary artery disease, mixed hyperlipidemia, and hypercholesterolemia. 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.Repatha SureClick is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the noted conditions would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Freestyle Libre 14 Day Sensor prescribed for diabetes. 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.Supplies for testing and monitoring blood glucose levels are not considered Part D drugs, and may be covered under the Medicare Part B Durable Medical Equipment benefit.A physician reviewed your appeal and determined that the requested diabetic monitoring equipment is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage and a tiering exception request for Xifaxan 550 milligram tablets. The Part D plan denied coverage for the medication and the tiering exception request because the medication was being prescribed for a non-medically accepted indication. We received the case to perform 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 indicates that Xifaxan has been prescribed for small intestinal bacterial overgrowth and unspecified chronic diarrhea. However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Disopyramide Phosphate 100 milligram capsules to treat sick sinus syndrome.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Enbrel Mini 50 milligram per milliliter subcutaneous injection pen. 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. Enbrel Mini, which is included in Tier 5 of the plans formulary, has been approved for coverage by the plan. 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 coverage at a lower-cost tier. A physician reviewed your appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 5 milligrams capsule prescribed to treat chronic pain and quadriplegia following a motor vehicle accident. 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 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 Dronabinol 5 milligrams capsule.