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

You requested Sildenafil Citrate 20 milligram tablets prescribed to take 1 tablet, by mouth, 3 times a day to treat Raynauds 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 medical records show your doctor prescribed Sildenafil Citrate 20 milligram tablets to treat Raynauds syndrome. According to DRUGDEX, Sildenafil Citrate is indicate as non-Food and Drug Administration use for secondary Raynauds phenomena. DRUGDEX states, Sildenafil significantly improves microcirculation in patients with secondary Raynaud phenomenon resistant to vasodilator therapy in a double-blind, placebo-controlled, crossover study.The clinic office note dated June 11, 2021, indicates that upon the last hospital admission, the enrollee was treated aggressively with vasodilators and pain management for significant digital ulceration of upper and lower extremities, distally. The reconsideration appeal letter dated June 21, 2021, shows the enrollee suffers from systemic lupus erythematosus with Raynauds phenomena. The prescriber states, She developed earlier this year significant vasculopathy in the form of advanced Raynauds phenomena vascular occlusion and gangrene. This was believed to be autoimmune dictated based on her serologies and previous history of autoimmune illness (systemic lupus erythematosus). Therefore, the documentation provided by your physician supports that that you have a medically accepted indication for the requested drug.A physician reviewed your appeal and determined that the plan is required to cover Sildenafil Citrate 20 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sublocade 100 milligram per 0.5 milliliter syringe prescribed every 30 days for opioid dependence with withdrawal. 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 record shows Sublocade is being prescribed to the enrollee for treatment of opioid dependence with withdrawal. Medicare law specifically excludes coverage for any drug for which payment would be available under Medicare Parts A or B for that individual. Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner). Sublocade must be prepared and administered by a clinician. The records show that the drug was administered in the physicians office. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Sublocade. Please consider submitting this 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 is Neupro 2 milligram/24 hour patch, a quantity of 30 patches for 30 days prescribed for Parkinsons disease. 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. Neupro 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. 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 Adempas 2.5 milligram tablet prescribed three times daily for pulmonary arterial hypertension with connective tissue disease. 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 shows the doctor prescribed Adempas to treat the enrollees pulmonary arterial hypertension with connective tissue disease. This supports a medically accepted indication. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records and right heart catheterization show the enrollee has World Health Organization group 1 pulmonary arterial hypertension. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Adempas.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligram tablet prescribed for insomnia. 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 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. Your medical records show your doctor prescribed Zolpidem Tartrate to treat your insomnia. 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 Zolpidem Tartrate. 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

You requested Lidocaine 5% patch prescribed 30 patches every 30 days for cervical disc 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 records 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.Your medical records show your doctor prescribed Lidocaine 5% patch to treat your cervical disc disorder.  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 request for coverage of Nurtec ODT 75 milligram orally disintegrating tablets, which have been prescribed for migraine, unspecified, not intractable, without status migrainosus. 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. Nurtec ODT is not included in the plans formulary (list of covered drugs). 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 enrollees 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

At issue is Belbuca 300 microgram file prescribed daily for chronic 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. In order to grant an exception for a drug not on the plans formulary,  all alternative formulary drugs must have been tried, failed, or deemed contraindicated. A physician reviewed your appeal and determined that the plan is not required to cover Belbuca.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyanocobalamin 1000 microgram/ milliliter solution prescribed for vitamin B-12 deficiency. 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. We determined that the plan is not required to cover Cyanocobalamin because it is a prescription vitamin and mineral product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations 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

You requested Doxepin Hydrochloride 100 milligram capsules. 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. A request for information was sent to the prescriber; however, no 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: Favorable

At issue is Actemra 162 milligram per 0.9 milliliter subcutaneous solution prescribed weekly for giant cell arteritis. 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 records submitted at the reconsideration level.The medical records show the doctor prescribed Actemra to treat your giant cell arteritis. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show you have the diagnosis of giant cell arteritis, the drug was prescribed by a rheumatologist, and you had tried and failed the glucocorticoid Prednisone. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Actemra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lupron Depot 45 milligrams for intramuscular injection prescribed as directed for prostate cancer. 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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested.The documentation shows the doctor prescribed Lupron Depot to treat malignant neoplasm of prostate (C61.0). However, the documentation available for review does not show the stage of cancer or the enrollees treatment history. It could not be determined whether the requested drug was prescribed for a medically accepted indication.  A physician reviewed your appeal and determined that the plan is not required to cover Lupron Depot.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets prescribed for constipation. 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 includes medical records and a physician supporting statement. The prescriber has indicated the enrollee has a diagnosis of irritable bowel syndrome with constipation. However, the medical records submitted do not support this diagnosis. The records indicate the enrollee has constipation. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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: Favorable

At issue is Humulin R U-500 vial 500 units per milliliter prescribed for type 2 diabetes mellitus. 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 records submitted at the reconsideration level.The medical records show the doctor prescribed Humulin R U-500 to treat the enrollees type 2 diabetes mellitus. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollee is not on a durable medical equipment insulin pump but uses the Omnipod Dash disposable system. The documentation provided shows the enrollee has satisfied the plan's coverage criteria and the service is eligible for coverage under Part D.A physician reviewed the appeal and determined that the plan is required to cover Humulin R U-500.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Dupixent 300 milligram per 2 milliliter subcutaneous injection syringe prescribed for atopic dermatitis. 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. Dupixent is not included in the plans formulary (list of covered drugs). 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 enrollees 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

At issue is a tiering exception request for Xtampza ER 18 milligram capsules 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.Xtampza ER 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 Humira CF pen 40 milligrams per 0.4 milliliters prescribed every two weeks for granuloma annulare. 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 shows the doctor prescribed Humira CF pen to treat the enrollees granuloma annulare. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Humira CF pen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Alogliptin Benzoate 25 milligram tablets prescribed for type 2 diabetes. 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. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Alogliptin Benzoate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Droxidopa 200 milligram capsule prescribed 60 capsules every 30 days for orthostatic hypotension. 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 Droxidopa to treat your orthostatic hypotension. 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 Droxidopa. Your orthostatic hypotension must be related to primary autonomic failure due to 1) Parkinsons disease, multiple system atrophy, or pure autonomic failure; or 2) Dopamine beta hydroxylase deficiency; or 3) non-diabetic autonomic neuropathy. 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 tiering exception request for Trulicity 1.5 milligram per 0.5 milliliter subcutaneous injection pen prescribed for type 2 diabetes with coronary artery disease. 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. Trulicity 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 the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Haloperidol 2 milligram tablet prescribed as a compounded drug 0.5 milligram per 5 milliliter via jejunostomy tube twice daily for anxiety and agitation. 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 shows the doctor prescribed Haloperidol to treat the enrollees anxiety and agitation. 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 Haloperidol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Latuda 20 milligram tablets 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.Latuda 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. 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 Livalo 1 milligram tablets prescribed daily for primary or secondary prevention of cardiovascular events. 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 medical records do 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 Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathioprine 50 milligram tablet prescribed twice daily for neurosarcoidosis. 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 shows the doctor prescribed Azathioprine to treat the enrollees neurosarcoidosis. 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 Azathioprine.