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

At issue is Piqray 300 milligram/day tablet prescribed for metastatic phosphatidylinositol-3-kinase mutated breast cancer. 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. The medical records show you prescribed Piqray 300 milligram/day tablet to treat the enrollees metastatic phosphatidylinositol-3-kinase mutated breast cancer in combination with Exemestane. 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 Piqray 300 milligram/day tablet. 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 Victoza 2-pack 18 milligram/3 milliliter pen prescribed as directed. 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. Victoza 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: Favorable

You requested Hydrocodone/Acetaminophen 7.5/325 milligram tablet, a quantity of 120 tablets per 30 days prescribed four times daily, as needed for degenerative joint 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 requested drug has quantity limit requirements. Your medical records show your doctor prescribed Hydrocodone/Acetaminophen to treat your degenerative joint disease. Your medical records further support that the quantity being requested is within the plans quantity limit for the number of doses that may be dispensed during a specific period of time. 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 Hydrocodone/Acetaminophen.
Appeal type: Prescription Drug
Decision: Favorable

You requested for Jakafi 15 milligram tablet prescribed for chronic myeloproliferative disease and other thrombocytopenia. The Part D plan denied the request because it was not a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia.At reconsideration Jakafi 15 milligram tablet, was prescribed, for what is clearly documented in the medical records as myeloproliferative neoplasm  essential thrombocythemia. It is also clearly documented that enrollee has failed escalating doses of hydroxyurea. A positive citation in NCCN, a Medicare approved compendium, supports the use of the requested drug for the condition indicated (myeloproliferative neoplasm  essential thrombocythemia), stating - Treatment for inadequate response or loss of response to hydroxyurea, peginterferon alfa-2a therapy or anagrelide (useful in certain circumstances). Therefore, it is considered a medically accepted indication.The documentation does not satisfy the plans coverage criteria. The plans coverage criteria state that you need to have an FDA approved indication.  Therefore, an exception to the plans coverage criteria is medically necessary. 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 Reclast 5-milligrams/100-milliliters to treat ate-related osteoporosis with current pathological fracture, unspecified. The Part D plan denied the request. The requested drug is not on the plans formulary. 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

You requested Buprenorphine 2 milligram sublingual tablets prescribed 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. The medical records show Buprenorphine 2 milligram tablets were prescribed to treat chronic pain due to low back pain. 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 Buprenorphine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Fentanyl 12 microgram per hour transdermal 72-hour patches prescribed for chronic pain due to cervical dystonia. 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. The documentation does not satisfy the plans coverage criteria for this medication. 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 Pregabalin 300 milligram capsule prescribed three times a day for fibromyalgia pain. 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 indicates your doctor prescribed Pregabalin to treat your pain. Medicare approved compendia does not support additional benefit from doses that exceed 450 milligrams a day. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozobax 5 milligram/5-milliliter solution prescribed for cerebral palsy, microcephaly, severe developmental delay, quadriplegia, and Lennox-Gastaut syndrome with intractable epilepsy. The Part D plan denied the request because the manufacturer of the drug at issue did not participate in the Medicare Gap Discount Program. We received an expedited request from the appellant to reconsider the appeal. 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 the manufacturer of the drug at issue, Metacel, does not participate in the Medicare Gap Discount Program. Payment cannot be allowed for a drug whose manufacturer does not participate in the Medicare Gap Discount Program.We determined that the plan is not required to cover the drug at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Diclofenac Sodium 1% gel prescribed for osteoarthritis of an unspecified site. 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. The documentation does not satisfy the plans coverage criteria for this medication. 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 Ajovy 225 milligram/1.5 milliliter auto-injector prescribed for chronic post-traumatic headaches. 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 Ajovy for chronic post-traumatic headaches. The Medicare approved compendia do not support the use of the drug at issue for your condition. 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 for Levalbuterol Tartrate 45 microgram inhaler prescribed for dyspnea. 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. The documentation shows your doctor prescribed Levalbuterol Tartrate to treat your dyspnea. 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 Levalbuterol Tartrate.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Forteo 620 microgram/2.48 milliliter pen injector prescribed for post-menopausal osteoporosis. 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 Forteo for post-menopausal osteoporosis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plan requires a contraindication or intolerance with an oral or intravenous bisphosphonate for coverage of Forteo. The documentation includes clinical notes which satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Forteo. The physician reviewer also determined that an exception to the plans prior authorization requirements can be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Enbrel Cartridge 50 milligram/milliliter prescribed to treat 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your prescriber indicates you have been on Embrel since 2018 and the drug is sufficient. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The enrollee must have had prior therapy with or intolerance to a single disease-modifying antirheumatic drug. The enrollee has not satisfied the plan's coverage criteria. A physician reviewed your appeal and determined that the plan is not required to cover Enbrel. 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 Guanfacine Hydrochloride 1 milligram tablet prescribed four times daily for physical aggressiveness. 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 Guanfacine Hydrochloride to treat the enrollees physical aggressiveness. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Guanfacine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cinacalcet 90 milligram tablets prescribed for end stage renal disease and hyperparathyroidism. 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 submitted documentation indicates you are currently on dialysis. The drug at issue is eligible for coverage under Part B. The drug is not eligible for Part D coverage.This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine Hydrochloride 25 milligram suppository prescribed as directed. 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. This drug is not included on your plans formulary. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Morphine Sulfate 30 milligram Suppositories prescribed to treat chronic pain due to fibromyalgia and Lyme 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 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. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage.  Morphine Sulfate Suppositories has not been found by the United States Food and Drug Administration to be safe and effective, and the drug product labeling has not been approved by the Food and Drug Administration. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to cover Morphine Sulfate Suppositories.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of ZTlido 1.8% patches prescribed for pain resulting from osteoarthritis of the hip and degenerative joint disease of the hip and knee. 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.ZTlido is not included in the plans formulary. The prescriber has not sufficiently addressed why all of the alternative medications that are 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 for Scopolamine 1 milligram/3 days patch for 72 hours prescribed for nausea and vomiting during infusions. 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. The documentation shows your doctor prescribed Scopolamine to treat your nausea and vomiting while you are receiving other medication infusions. 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 Scopolamine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Scopolamine 72 hour patch prescribed for nausea. 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 Scopolamine was prescribed to treat nausea associated with chemotherapy. 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 Scopolamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Singulair 10 milligram tablets prescribed for allergic rhinitis. 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 Singulair.
Appeal type: Prescription Drug
Decision: Favorable

You requested Xifaxan 550 milligram tablet prescribed for irritable bowel 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 Xifaxan to treat your irritable bowel syndrome. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Rifaximin (Xifaxan) is indicated for the treatment of irritable bowel syndrome with diarrhea in adults.A physician reviewed your appeal and determined that the plan is required to cover Xifaxin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vascepa 1 gram capsules prescribed for hypertriglyceridemia. 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 Vascepa for hypertriglyceridemia in an enrollee without established cardiovascular disease or diabetes, and without severe hypertriglyceridemia. 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: Unfavorable

At issue is Dupixent 300 milligram/2 milliliter pen for bullous pemphigoid. The Part D plan denied your request you did not have a Medicare approved compendia diagnosis.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 doctors statement and medical records show Dupixent was prescribed for bullous pemphigoid. The following citation in DrugDex, a Medicare approved compendium, supports the use of the requested drug for your condition: Orphan drug designation: Treatment of bullous pemphigoid'. Therefore, it is considered a medically accepted indication.However, 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 doctors statement and 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 Dupixent.
Appeal type: Prescription Drug
Decision: Favorable

You requested Scopolamine 0.33 milligram/24 hour patch prescribed for nausea associated with motion sickness. 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 Scopolamine patch for nausea associated with motion sickness. The Medicare approved compendia do support the use of the drug at issue for your conditions. A physician reviewed your appeal and determined that the plan is required to cover the requested drug.