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

At issue is Hydroxyzine Pamoate 25 milligram tablets prescribe to treat itchiness and muscle spasm.   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 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 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 Amphetamine ER 1.25 milligram/milliliter suspension prescribed for major depressive disorder. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The records show your physician prescribed Amphetamine ER 1.25 milligram/milliliter suspension to treat your major depressive disorder. 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 Amphetamine ER 1.25 milligram/milliliter suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 5 milligram tablets prescribed for insomnia. The Part D plan denied coverage.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 on hand did not include a supporting statement. A request for a supporting statement was submitted to your doctor. Your doctor submitted a supporting statement for the drug at issue. However, the statement does not support that you satisfy the plan's prior authorization coverage criteria.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 Lidocaine 5% ointment prescribed for pain of the right shoulder. 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 you prescribed Lidocaine 5% ointment to treat the enrollees right shoulder 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 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for neuropathic pain of the left shoulder. 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 you prescribed Lidocaine 5% patch to treat the enrollees neuropathic pain of the left shoulder. 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 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested is Methylphenidate Hydrochloride 5 milligram tablet, 60 tablets for 30 days prescribed twice daily for major depressive disorder and fatigue. 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 do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colistimethate Sodium Powder to treat cystic fibrosis, bronchiectasis, and pneumonia secondary to pseudomonas. 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.Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.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 Amphetamine/Dextroamphetamine 10 milligram tablets prescribed for unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescenceand multiple sclerosis. 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 prescriber initially provided the diagnosis of unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescenceand multiple sclerosis. In the request for reconsideration, the prescriber changed the diagnosis to attention deficit hyperactivity disorder. Medical records were not submitted to support the diagnosis of attention deficit hyperactivity disorder. The use of the requested drug to  unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescenceand multiple sclerosis is not a medically accepted indication. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 micrograms blisters with device prescribed daily for chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Anoro Ellipta 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 Ramelteon 8 milligram tablets prescribed for insomnia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any 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 adequately 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 Ramelteon 8 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5-milligram tablet prescribed to treat your condition. 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.Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 10 milligram tablet prescribed daily to twice a day for a quantity of 60 tablets for 30 days for neck pain, low back pain and cervicalgia. 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 Cyclobenzaprine Hydrochloride to treat your neck pain, low back pain and cervicalgia. However, the Medicare approved compendia do not support the use of this drug for this condition as prescribed.A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temazepam 22.5 milligram capsules prescribed as directed for insomnia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Temazepam to treat your insomnia. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.   A physician reviewed your appeal and determined that the plan is not required to cover Temazepam because the plans prior authorization requirements were not met. 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 Carisoprodol 350 milligram tablets prescribed six times daily. At determination and redetermination a diagnosis of musculoskeletal pain was provided. The Part D plan denied your request as not a medically accepted indication. 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. At reconsideration, the documentation shows your doctor prescribed Carisoprodol to treat your chronic low back pain and you have been on this medication for years. The medical record of April 22, 2021 validates this diagnosis. A citation in Micromedex, a Medicare approved compendium, supports the use of the requested drug for the condition indicated:  Carisoprodol was superior to propoxyphene in improving range of movement, but approximately equivalent to propoxyphene in improving sleep in a placebo-controlled study involving 94 patients with pain due to muscle spasm and/or stiffness associated with acute or chronic low-back syndrome. Therefore, it is considered a medically accepted indication.Howwever, this drug is not on your plans formulary. 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 Zolpidem Tartrate tablet to treat insomnia. The Part D plan denied the request.  We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes 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 Abraxane 100 milligram intravenous suspension prescribed for ampullary adenocarcinoma. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. We received the documentation and included it in our review.The records show you prescribed Abraxane 100 milligram intravenous suspension to treat the enrollees ampullary carcinoma. The National Comprehensive Cancer Network indicates that ampullary cancers can be treated as pancreatic or biliary cancers. Per the National Comprehensive Cancer Network, Abraxane in combination with Gemzar is an appropriate treatment option for this enrollee. However, this drug is eligible for coverage under Medicare Part B. This medication cannot be self-administered and will need to be provided incident to a healthcare professional service. We determined that the plan is not required to cover Abraxane 100 milligram intravenous suspension. You may wish to submit you claim to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligrams/milliliter injection pen prescribed as directed for atherosclerotic heart disease of native coronary artery without angina pectoris, and hyperlipidemia, 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. We also researched Medicare systems and reviewed the enrollment data available. Repatha is a biological product drug on Tier 3 of the plans formulary. There are no biological product 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 Botox 100 units solution prescribed for facial postherpetic neuralgia. 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 prescribers statement shows Botox was prescriber to treat facial postherpetic neuralgia. 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 Botox.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligram tablets. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The prescriber indicates on a questionnaire that you do not have a diagnosis of pulmonary arterial hypertension. Your plan has prior authorization requirements for this drug that states this drug is covered for pulmonary arterial hypertension with proper documentation. The prior authorization requirements were not met.  A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil Citrate as the prior authorization requirements were not met. 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 Linzess 290 microgram oral capsule prescribed daily for irritable bowel 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.Linzess 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 a tiering exception request for Prolia syringe, 60 milligrams per milliliter, to treat the enrollees condition. The Part D plan denied the request for a tiering exception.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.Prolia syringe, 60 milligrams per milliliter, is a biologic drug on Tier 3 of the plans formulary. There are no biologic drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Skyrizi Dose Kit 150 milligrams-2 syringes for psoriasis vulgaris. 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 Skyrizi to treat your psoriasis vulgaris. 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. The prescriber indicates the enrollee has not tried prior therapy or was intolerant to a single conventional oral systemic treatment or all conventional oral systemic treatments are contraindicated.A physician reviewed your appeal and determined that the plan is not required to cover Skyrizi. 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 Vascepa 1 gram capsules. 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. Vascepa 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 prescribed Zolpidem Tartrate 10 milligram oral tablet for insomnia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.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 received the documentation and included it in our review.The prescriber submitted a supporting statement with answers to prior authorization requirements. The prescriber statement shows Zolpidem Tartrate was prescribed to treat insomnia. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria. There were no medical records provided for review.A physician reviewed your appeal and determined that the plan is not required to cover Zolpidem. 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 Diclofenac Sodium 1% gel prescribed to apply 4 grams topically four times daily for the diagnosis of right foot 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 prescriber states the requested drug is being used to treat right foot pain in an enrollee with gout and chronic kidney disease. 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 your appeal and determined that the plan is not required to cover Diclofenac Sodium 1% gel.