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

You requested Xifaxan 550 milligram tablets prescribed for small intestinal bacterial overgrowth. 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 Xifaxan for small intestinal bacterial overgrowth. The Medicare approved compendia do not support the use of the drug at issue for your conditions. Your doctor submitted a statement to indicate your diagnosis should be irritable bowel syndrome with diarrhea; however, the medical records submitted do not support the drug was prescribed for this diagnosis. 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

You requested Entocort 3 milligram capsule prescribed two capsules once daily for possibility of immune mediated colitis due to cancer immunotherapy. 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 Entocort possibility of immune mediated colitis due to cancer immunotherapy. 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 Entocort.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sodium Bicarbonate Solution 4.2% for inhalation via nebulizer route prescribed for low lung function in an enrollee with cystic fibrosis. 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 will be using the solution via a nebulizer. Sodium Bicarbonate Solution 4.2% is not approved by the Food and Drug Administration for inhalation treatments. Therefore, the drug is not eligible for coverage under Part D drug benefits. We determined that the plan is not required to cover Sodium Bicarbonate Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cinacalcet Hydrochloride 30 milligram tablet prescribed daily for hypercalcemia due to primary hyperparathyroidism. 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.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.The medical records show the doctor prescribed Cinacalcet Hydrochloride to treat the enrollees hypercalcemia due to primary hyperparathyroidism. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollee has chronic kidney disease and is not receiving dialysis. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Cinacalcet Hydrochloride. 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 Pregabalin 75 milligram capsules prescribed three times daily 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.Pregabalin is a generic drug on Tier 2 of the plans formulary. Your doctor submitted a supporting statement. The documentation on hand does not address why all alternative lower-tier medication on the plans formulary would not work for you. All generic 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 Latuda 20 milligram tablets prescribed for severe episode of major depression with psychotic features. 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 prescriber indicates that Latuda is prescribed for severe episode of major depression with psychotic features. 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 Latuda.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested for Humira 40 milligram/0.4-milliliter pen prescribed for sarcoidosis. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation shows your doctor prescribed Humira to treat your sarcoidosis. 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 Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Febuxostat 40 milligram tablet prescribed daily for gout. 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 your appeal and determined that the plan is not required to cover Febuxostat.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a quantity limit exception for Bevespi Aerosphere 5.9 gram inhaler 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.The submitted documentation does not include a supporting statement or medical records. A request for additional information was sent to your doctor; however, no documentation was received. There is no corroborating evidence of a prescribed diagnosis. As it cannot be determined that the drug was prescribed for a medically accepted indication, a quantity limit exception 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

You requested Saxenda 18 milligram/3-milliliter pen injector to promote weight loss. 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.We determined that the plan is not required to cover Saxenda because it was prescribed to promote weight loss. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eylea 2 milligram/0.05 milliliter prefilled syringe prescribed for central retinal vein occlusion with macular edema. 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 does not include medical records or a supporting statement. A request for a records was sent to your doctor; however, no documentation was received. The documentation on hand does not contain evidence to support the prescribed diagnosis. As it cannot be determined that the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lonsurf 20-8.19 milligram oral tablets to treat metastatic colon cancer in an enrollee not previously treated with an Irinotecan-based regimen. 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. 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 Privigen 10% Vial prescribed for secondary immunodeficiency disorder. 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. Your prescriber has indicated that you have secondary immunodeficiency disorder which requires treatment with Privigen. 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 Privigen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gamunex-C 10 gram/100 milliliter vial prescribed for peripheral polyneuropathy associated with Sjorgens disease. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Gamunex-C  prescribed for peripheral polyneuropathy associated with Sjorgens disease. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dalvance 500 milligram injection prescribed for osteomyelitis. 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. 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 Dalvance.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxycodone Hydrochloride Extended Release tablets prescribed 180 tablets per 30 days for pain relief. The Part D plan approved a request for prior authorization of this drug up to the maximum dispensing limit of 90 tablets per 30 days through December 31, 2021, but denied the initially requested amount of 180 tablets per 30 days as it is greater than whats usually allowed.  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 requested additional information from your prescriber to confirm the quantity required and ask for documentation to support why the amount requested, 180 tablets per 30 days, was required. We did not receive a response. A physician reviewed your appeal and determined that the plan is not required to cover 180 tablets per 30 days of Oxycodone Hydrochloride Extended Release tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone 1.62% gel prescribed for testicular hypofunction. 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 originally prescribed Testosterone for testicular hypofunction. The medical records submitted support you have a diagnosis of hypogonadism. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Memantine Hydrochloride 5 milligram tablets prescribed daily for Parkinsons disease and frontal lobe and executive function deficit. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows Memantine Hydrochloride was prescribed to treat the enrollees Parkinsons disease and frontal lobe and executive function deficit. 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 Memantine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 10/20/30 milligram starter pack 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. Your medical records show your doctor prescribed Otezla for 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.A physician reviewed your appeal and determined that the plan is not required to Otezla. 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 Vagifem 10 microgram tablet prescribed for your condition. 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 provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xolari 150-milligram 2.5 Vials per 30 days to treat asthma. 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 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

At issue is Cytomel 5 microgram tablet prescribed for hypothyroidism. 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 provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is DDAVP 0.1 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 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 provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 100 microgram tablet prescribed daily for hypothyroidism. The Part D plan denied the 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.This drug is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed the 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 Bempedoic Acid 180 milligram tablet prescribed for atherosclerotic cardiovascular disease and hypercholesterolemia. 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.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 Bempedoic Acid 180 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Ocrevus 300 milligram/10 milliliter solution prescribed for secondary progressive multiple sclerosis. 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. A request for additional information was sent to the prescriber; however, no further documentation was received. Medical records were provided which support the diagnosis of secondary progressive multiple sclerosis.  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 Ocrevus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sirolimus 2 milligram tablets prescribed for other lymphoid leukemia not having achieved remission. 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 prescriber indicates they prescribed Sirolimus for lymphoid leukemia not having achieved remission. However, Medicare approved compendia does not support this drug for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Sirolimus.