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

You requested Horizant ER 600 milligram tablets prescribed for drug induced akathisia. 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 Horizant ER to treat your drug induced akathisia. 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 Horizant ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trospium Chloride 20 milligram tablets to treat the enrollees condition. 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 Trospium Chloride 20 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyproheptadine Hydrochloride 4 milligram tablets prescribed for chronic cough related to sarcoidosis. 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 Cyproheptadine Hydrochloride for chronic cough related to sarcoidosis. The Medicare approved compendia do not support the use of this drug for your condition. 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 Hydrocodone Bitartrate 45 milligram compounded capsules from bulk crystals. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The record shows you were prescribed Hydrocodone Bitartrate compounded capsules from bulk crystals. Drugs compounded from bulk powders/crystals are not Food and Drug Administration approved and are therefore not covered under Part D. The plan is therefore not required to cover the Hydrocodone Bitartrate crystals at issue. We determined that the plan is not required to reimburse the Hydrocodone Bitartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Actemra 162 milligrams/0.9 milliliter injection prescribed for refractory relapsing polychondritis. 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 records show your physician prescribed Actemra 162 milligrams/0.9 milliliter to treat your refractory relapsing polychondritis. However, the Medicare approved compendia do not support the use of this biologic for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Actemra 162 milligrams/0.9 milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Travoprost 0.004% solution prescribed primary open-angle glaucoma. 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. You may wish to submit a request to the plan to consider an off-formulary exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Voriconazole 40 milligram/milliliter suspension prescribed for lung transplant status. 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 Voriconazole to treat your lung transplant status. 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 Voriconazole.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine Hydrochloride 2% Gel prescribed as 30 milliliters per 7 days to treat severe back pain. The Part D plan denied the request due to not being medically indicated for the enrollees condition and the quantity requested is over the plan quantity limits. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and reviewed the enrollment data available. The records show you prescribed Lidocaine Hydrochloride 2% Gel 30 milliliters per 7 days for back pain. Lidocaine Hydrochloride 2% Gel is not medically indicated for this condition. In addition, the quantity requested is over the limit allowed by the plan. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine Hydrochloride 2% Gel 30 milliliters per 7 days.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hetlioz 20 milligram tablets prescribed the enrollees condition. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.We asked the prescriber to send us medical records or other documentation to show why you need the medication. The prescriber responded stating the medication was discontinued on May 28, 2020. Therefore, the plan is not required to cover the Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amphetamine-Dextroamphetamine 20 milligram tablets prescribed for narcolepsy. 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.The records submitted include a statement from your physician indicating that you are prescribed Amphetamine-Dextroamphetamine 20 milligram tablets for narcolepsy. We requested medical records to support a diagnosis of narcolepsy confirmed by sleep study; however, no medical records were received. 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 you have satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Amphetamine-Dextroamphetamine 20 milligram tablets. 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 Forteo Solution Pen Injector 620 microgram/2.48 milliliters prescribed for osteoporosis. 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. We also researched Medicare regulations and reviewed the enrollment data available. The documentation shows you were prescribed Forteo Solution Pen Injector to treat your osteoporosis. 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 Forteo Solution Pen Injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mirena 52 milligram intrauterine device prescribed as directed for abnormal vaginal bleeding and thickened endometrium. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. 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 Mirena.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Morphine Sulfate 15-milligram Extended Release tablet to treat pain. The Part D plan denied the request.  We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided 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

At issue is Otezla Starter Pack 10-20-30-milligram tablets to treat arthropathic psoriasis. 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 Ketoconazole 2 percent foam prescribed daily for tinea pedis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Ketoconazole 2 percent foam to treat your tinea pedis. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and  determined that the plan is not required to cover the Ketoconazole 2 percent foam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyndamax 61 milligram capsule prescribed for cardiac amyloidosis. 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 Vyndamax to treat your cardiac amyloidosis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. No new medical records, to validate the change in the prior authorization criteria answers, were provided. 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 Vyndamax. 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 Oxycotin 10 milligram Extended Release tablets prescribed as two tablets a day for abdominal pain in enrollee with pancreatic 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 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 Oxycotin 10 milligram Extended Release Tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dipyridamole 50 milligram tablets prescribed for atrophic blanche. 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 Dipyridamole to treat your atrophic blanche. 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 Dipyridamole.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Unithroid 75 microgram tablets prescribed once daily for hypothyroidism, unspecified. 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. Unithroid is a Brand drug on Tier 3 of the plans formulary. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you. 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 Gemfibrozil 600 milligram tablets prescribed to treat your condition. 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 the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.Your doctor prescribed Gemfibrozil 600 milligram tablets to treat your condition. However, there is no documentation to justify the addition of the requested drug to your medication regimen despite a possible adverse reaction.A physician reviewed your appeal and determined that the plan is not required to cover Gemfibrozil 600 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Cypionate Solution 200 milligram/milliliter per 28 days prescribed for hypogonadism. 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 medical records show your doctor prescribed Testosterone Cypionate to treat your hypogonadism. 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 Testosterone Cypionate Solution. The records submitted do not support primary or hypogonadotropic hypogonadism. 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 Olumiant 2 milligram tablets prescribed to treat the diagnosis of 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 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 Olumiant 2 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Neupro 4 milligram/24 hour patches prescribed daily for restless leg syndrome. 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. We also researched Medicare systems and reviewed the enrollment data available. Neupro 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

You requested Pregabalin 50 milligram capsules prescribed twice a day to treat sacroilitis, chronic pain syndrome, and neuropathic pain. 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. We also researched Medicare regulations and reviewed the enrollment data available. The records show you were prescribed Pregabalin for sacroilitis, chronic pain syndrome, and neuropathic pain. Pregabalin is not medically indicated for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Omega-3-Acid Ethyl Esters 1 gram capsules prescribed for widespread myalgia and arthralgia. 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 Omega-3-Acid Ethyl Esters to treat your widespread myalgia and arthralgia. 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 the Omega-3-Acid Ethyl Esters. The Medicare approved compendia do not support the use of this drug for widespread myalgia and arthralgia. 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 Otezla Tab Ther Pack 10, 20, and 30 milligrams prescribed as directed for other lichen planus. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Otezla to treat your other lichen planus. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and  determined that the plan is not required to cover the Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Thyquidity 20 microgram/milliliter oral solution prescribed for hypothyroidism. 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 all the 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 Thyquidity.