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

You requested First-omeprazole suspension prescribed for the treatment of food avoidance and possible reflux esophageal. 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.According to the Food and Drug Administration, First-omeprazole is not listed on the NSDE file as an approved drug. Therefore, we determined the plan is not required to cover the First-omeprazole. 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 Repatha Sureclick 140 milligrams/milliliter injection to treat hyperlipidemia. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation provided addressed the plans coverage criteria, and those criteria were not satisfied. 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 Lidocaine 5 percent patch prescribed as directed for monoclonal gammopathy, unspecified mononeuropathy bilateral lower limbs, total body pain, and hereditary and idiopathic neuropathy unspecified. 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. The use of the requested drug to treat the provided diagnoses 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 these conditions. 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 Lidocaine 5 percent patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stelara Solution 90 milligrams per milliliter to treat pyoderma gangrenosum. 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 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: Favorable

You requested coverage for Tadalafil 20 milligram tablets. 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 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 submitted medical records indicate that Tadalafil has been prescribed for pulmonary hypertension, precapillary. Cardiac catheterization results included in the medical records indicate a mean pulmonary artery pressure of 34 with a pulmonary capillary wedge presure of 12 mmHg consistent with a diagnosis of pulmonary artery hypertension  The Medicare approved compendia do contain citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a medically accepted indication and is eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is required to cover the Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta prescribed for pseudobulbar affect. The Part D plan denied your request. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. 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.A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.  A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise 600-milligram tablet to treat chronic pain syndrome. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 Buprenorphine hydrochloride 2 milligram sublingual tablets prescribed as directed for chronic pain related to radiculopathy of the lumbar region. 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 shows the doctor prescribed Buprenorphine hydrochloride sublingual tablets to treat your condition. However, the Medicare approved compendia do not support the use of this drug in sublingual form for chronic pain related to radiculopathy lumbar region.A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Promethazine Hydrochloride 12.5 milligram tablets prescribed for trigeminal neuralgia. 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 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.At reconsideration, the prescribing physician has noted that the enrollee has nausea and vomiting. However, the Medicare approved compendia do not contain any citations to support the use of Promethazine Hydrochloride for nausea and vomiting that is unrelated to preoperative and postoperative surgery. Additionally, the Medicare approved compendia do not contain any citations to support the use of Promethazine Hydrochloride in the treatment of trigeminal neuralgia. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Promethazine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Welchol 625 milligram tablet prescribed three tablets twice daily for chronic diarrhea associated with radiation enteritis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia does not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the Welchol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jariance 10-milligram tablet to treat diabetes mellitus. 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

At issue is Armodafinil 250 milligram tablet. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The physician submitted a supporting statement. The prescriber statement indicates that Armodafinil is prescribed to treat fatigue and excessive daytime sleepiness secondary to multiple sclerosis. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Tirosint 88 microgram 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.Tirosint is a brand drug on Tier 3 of the plans formulary. Your doctor submitted a supporting statement. The statement did not address why all alternative lower-tier medication on the plans formulary would not work for you. All brand drugs on lower tiers have not been tried. 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 Nourianz 20 milligram tablet prescribed as directed to treat Parkinsons disease. 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 records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Nourianz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prior authorization for Amitiza 24 microgram capsules prescribed daily for other constipation which is also noted as slow transit constipation. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. 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 Amitiza for other constipation. In review of the Medicare approved compendia, other constipation is not a medically accepted indication for Amitiza. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Amitiza at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycotin ER 30 milligram tablets every 12 hours to treat chronic pain related to lung cancer. The Part D plan denied the request. The requested drug is not on the plans formulary. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has provided patient specific clinical rationale and medical records. However, the documentation does not address 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

At issue is Guanfacine one milligram extended release tablet prescribed for your hypertension. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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 records submitted at the reconsideration level. The documentation supports the drug was prescribed for your diagnosis of hypertension. However, the documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria by acknowledging the benefit of therapy with this medication outweighs the potential risks identified by the American Geriatrics Society. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Linzess 145 microgram capsules prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because Linzess is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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 systems and reviewed the enrollment data available. The plan shows Linzess is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Spiriva Respimat 2.5 microgram inhaler prescribed for chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception because Spiriva Respimat is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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 systems and reviewed the enrollment data available. The plan shows Spiriva Respimat is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Stiripentol 250 milligram capsules prescribed daily for intractable severe infantile myoclonic epilepsy with status epilepticus. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. 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 Stiripentol for intractable severe infantile myoclonic epilepsy with status epilepticus. The initial diagnosis listed was intractable epilepsy associated with a Dravet's syndrome phenotype as well as tuberous sclerosis. The medical records submitted do not support a diagnosis of intractable severe infantile myoclonic epilepsy with status epilepticus, which is the only diagnosis supported in the Medicare approved compendia.Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover Stiripentol at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Dronabinol 5 milligram capsules prescribed daily for chronic, lower lumbar back pain associated with radicular, neuropathic pain in both lower extremities. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. 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 Dronabinol for chronic, lower lumbar back pain associated with radicular, neuropathic pain in both lower extremities. In review of the Medicare approved compendia, chronic, lower lumbar back pain associated with radicular, neuropathic pain in both lower extremities is not a medically accepted indication for Dronabinol. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Dronabinol at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Premarin 0.625 milligram vaginal cream prescribed for atrophic vulva. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. 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 Premarin for atrophic vulva. The Medicare approved compendium supports the use of this drug for your condition.Therefore, it does meet the definition of a Part D drug. The plan is required to cover the Premarin at issue.
Appeal type: Prescription Drug
Decision: Favorable

You requested Imuran 50 milligram tablets prescribed to prevent rejection from a kidney transplant. 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 received a kidney transplant on January 11, 1994, which was not covered under Medicare Part A. According to Medicare enrollment records, you were not entitled to Medicare Part A coverage at the time of the transplant. Therefore, your transplant is not considered a Medicare covered transplant and Imuran is not eligible under Medicare Part B. Therefore, we determined that the Part D plan is required to cover the Imuran.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Premarin 0.625 milligram per gram cream prescribed for vaginal atrophy. The Part D plan denied your request for a tiering exception because Premarin is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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 systems and reviewed the enrollment data available. The plan shows Premarin is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Shingrix 0.1 milligram per milliliter vaccine and administration prescribed for prophylaxis. The Part D Plan did not make a decision.We performed an independent and de novo review. We reviewed all documentation submitted. The record shows the enrollee is over 50 years of age and received the Shingrix vaccine. Proof of payment was submitted.We determined that the plan is required to reimburse you for the Shingrix vaccine and administration.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hetlioz 20 milligram capsules. 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.We were unable to obtain medical records from your prescriber. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the Hetlioz.