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

At issue is a request for coverage of Ambrisentan 5 milligram tablet prescribed for failing Fontan- double inlet left ventricle with pulmonary stenosis, atrioventricular block with moderate left ventricle dysfunction, systolic and diastolic heart failure, and increased Fontan pressure. 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. The documentation shows Ambrisentan was prescribed for failing Fontan- double inlet left ventricle with pulmonary stenosis, atrioventricular block with moderate left ventricle dysfunction, systolic and diastolic heart failure, and increased Fontan pressure. However, the Medicare approved compendia do not support the use of this drug for the enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Ambrisentan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tetracycline Hydrochloride 250-milligram capsules prescribed for perioral dermatitis. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited 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. The prescriber initially provided the diagnosis of perioral dermatitis.  In the request for reconsideration, the prescriber changed the diagnosis to acne.  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 use of the requested drug to treat perioral dermatitis is not supported in the Medicare approved compendia.  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 Lidocaine 5% patch prescribed for an unknown 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 your prescriber to send us answers to prior authorization coverage criteria and medical records. However, we did not receive the documentation.At reconsideration a diagnosis of radiculopathy, cervical region, other spondylosis with myelopathy, cervical region, and arthrodesis status were given. No medical records were provided by the prescriber to support these diagnoses. It could not be determined whether the requested drug was being prescribed for medically accepted indications. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 Ajovy 225 milligram/1.5 milliliter solution auto injector prescribed as directed for migraine without aura, not intractable, without status migrainosus. 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. This medication is not on your plan's list of medications. The prescriber has not given a clear and valid medical reason why all medications required by the plan, on that list, did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. Therefore, an exception to the plans formulary coverage criteria is not supported. A physician reviewed your appeal and determined that the plan is not required to cover Ajovy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Oxycodone-Acetaminophen 10-325 milligram tablets. 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. During this review, a request was submitted to the prescriber to address the coverage of this medication and to submit a prescriber statement of medical necessity and supporting medical records. The prescriber did not submit a letter of medical necessity or address the coverage of this drug. However, progress notes from a physicians office visit for the date of June 27, 2021, were submitted that indicate the enrollee is being treated for moderate to severe chronic pain due to multiple chronic conditions, which is a medically accepted indication outlined in the Medicare approved compendia. However, the progress notes indicate that the enrollee is concurrently taking multiple drugs that each interact with the requested drug, which is an opioid. These drugs include: Acetaminophen-Codeine 300-30 milligram tablet (an opioid); Cyclobenzaprine 10 milligram tablet (a centrally acting muscle relaxant); and Clonazepam 1 milligram tablet (a benzodiazepine). As outlined in the Medicare approved compendium, DRUGDEX, concurrent use of opioids with benzodiazepines and centrally acting muscle relaxants result in an increased risk of respiratory and central nervous system depression. The prescriber has noted in the progress notes that the enrollee is not willing to decrease his use of the clonazepam (a benzodiazepine) and prescribes the enrollee Narcan, which a drug used for the emergency reversal of respiratory depression. Due to the multiple potential drug-drug interactions and safety concerns, it has been determined that coverage for the requested drug will not be allowed. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine 5% patch for low back pain secondary to vertebral compression fracture. 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 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 Lidocaine 5% patch was prescribed to treat low back pain secondary to vertebral compression fracture. 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sildenafil Citrate 20 milligram tablets. The Part D plan denied the request stating that drugs prescribed for the treatment of erectile dysfunction are excluded from coverage under Medicare Part D. 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 prescriber has noted that Sildenafil Citrate is not being prescribed for the treatment of erectile dysfunction; rather, the drug has been prescribed for the treatment of the enrollees pulmonary arterial hypertension. The use of Sildenafil Citrate in the treatment of pulmonary arterial hypertension is a medically accepted indication outlined in the Medicare approved compendia. However, the Part D plan has prior authorization requirements for this drug when being prescribed for the treatment of pulmonary arterial hypertension. During this review, a request was submitted to the prescriber to address the plans prior authorization requirements and to provide supporting medical records. However, the prescriber did not respond to the request. Therefore, it is not possible to confirm that the plans coverage criteria have been satisfied with the available documentation. As such, the requested drug is not eligible for coverage. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine Hydrochloride 12.5 milligram tablets prescribed to treat chronic nausea with vomiting from an undetermined source. The Part D plan denied the appeal request.The QIC 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 Promethazine Hydrochloride 12.5 milligram tablets to treat an enrollee with chronic nausea with vomiting from an undetermined source. However, the Medicare approved compendia do not support the use of this drug for the condition. A physician reviewed the appeal and determined that the plan is not required to cover Promethazine Hydrochloride 12.5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clonidine Hydrochloride 0.1 milligram tablet prescribed for attention deficit hyperactivity disorder, unspecified type. 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. The prescriber indicates that Clonidine Hydrochloride tablets are requested to treat attention deficit hyperactivity disorder, unspecified type. 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 Clonidine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Epidiolex 100 milligram/milliliter solution prescribed as directed for seizures. 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 documentation shows your doctor prescribed Epidiolex to treat your seizures. 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 Epidiolex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methscopolamine Bromide 2.5 milligram tablets to treat the enrollees condition. The Part D plan denied the appeal request stating that the provided diagnoses (gastroparesis and gastritis) were non-medically accepted indications.The QIC 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.Upon reconsideration, the documentation shows the doctor prescribed Methscopolamine Bromide 2.5 milligram tablets to treat allergic or non-allergic rhinitis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Methscopolamine Bromide 2.5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira 80 milligrams per 0.8 milliliter prescribed subcutaneously 160 milligrams day one, 80 milligrams day 15, then 40 milligrams day 29 and every other week for microscopic colitis and chronic diarrhea. 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 doctor prescribed Humira to treat the enrollees microscopic colitis and chronic diarrhea. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed the appeal and determined that the plan is not required to cover Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxycodone 5 milligram tablets, 18 per day, to treat chronic pain 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 Oxycodone to treat your chronic pain syndrome. However, the accumulated morphine milligram equivalent of one or more of the enrollee's opioid prescriptions is 210 milligrams per day. The plan has a limit of 200 milligram morphine equivalent dosing per day.A physician reviewed your appeal and determined that the plan is not required to cover the Oxycodone, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxazepam 15 milligram capsule prescribed daily for insomnia. 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. 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. A physician reviewed the appeal and determined that the plan is not required to cover Oxazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 2.5 milligram tablet. 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 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. Eliquis 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 Wegovy 2.5 milligrams per 0.75 milliliters solution auto-injector prescribed to treat obesity. The Part D plan denied the appeal 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 enrollee was prescribed Wegovy 2.5 milligrams per 0.75 milliliters solution auto-injector to treat obesity. We determined the plan is not required to cover Saxenda because it is excluded from coverage under Part D. 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 Afrezza powder 12 units inhaled daily prescribed for type 1 diabetes mellitus. The Part D plan did not make a decision.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. 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. A physician reviewed the appeal and determined that the plan is not required to cover Afrezza powder.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz 5 milligram tablet prescribed for rheumatoid arthritis with rheumatoid factor of multiple sites without organ or system involvement. 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. This drug is not on your plan's formulary. 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 prescriber does not indicate why all other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligram extended-release tablets. The Part D plan denied the appeal 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.Myrbetriq 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Contrave ER 12HR 8/90 milligram tablet prescribed to treat obesity. 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.The record shows you were prescribed Contrave for the treatment of weight gain. We determined the plan is not required to cover Contrave because it is excluded from coverage under Part D. If you purchased drugs/products that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug/product. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Ointment 5% Ointment prescribed for chronic midline back pain without sciatica and bilateral knee 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. The prescriber indicates that Lidocaine Patch 5% Ointment is prescribed for chronic midline back pain without sciatica and bilateral knee pain. 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 Lidocaine Ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% Ointment prescribed for shoulder and knee 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. The prescriber indicates that Lidocaine 5% Ointment is prescribed for shoulder and knee pain. 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 Lidocaine Ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 100 milligram tablet prescribed daily for a cerebrovascular accident and cognitive/memory deficits. 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 doctor prescribed Modafinil to treat the enrollees cerebrovascular accident and cognitive/memory deficits (post stroke fatigue). However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed the appeal and determined that the plan is not required to cover Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Famciclovir 500 milligram tablet prescribed for trigeminal neuralgia. 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. The prescriber indicates that Famciclovir is requested to treat trigeminal neuralgia. However, the Medicare approved compendia do not support the use of this drug for this condition. A tiering exception will not be considered for a drug that is not supported for use. A physician reviewed your appeal and determined that the plan is not required to cover Famciclovir.