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

You requested Lidocaine 5% patch prescribed to treat chronic low back pain associated with lumbar canal stenosis. 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.You requested Lidocaine 5% patch to treat chronic low back pain associated with lumbar canal stenosis. No recent medical records have been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.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 Metaxalone 800 milligram oral tablet prescribed. 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. However, we did not receive the documentation.At initial determination the diagnosis of low back pain was given. The prescriber submitted a prior authorization form that shows Metaxalone was prescribed to treat chronic lumbar radiculopathy, cervical radiculopathy, and myositis. However, no medical records have been submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia. As such, the formulary exception was not addressed because 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 Metaxalone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligrams per 2 milliliters pre-filled syringe prescribed to treat atopic dermatitis affecting arms and legs. 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 indicates that several of the plans alternative formulary drugs were tried and failed or could cause harm. 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. In this case, the records do not support why all 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 Dupixent 300 milligrams per 2 milliliters pre-filled syringe.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amitriptyline 10 milligram oral tablet. 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. 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.There was no diagnosis submitted at initial determination or at redetermination. No medical records have submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia. As such, 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 Amitriptyline.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Fluororacil-Calcipotriene cream prescribed for unknown diagnosis. 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 the Fluororacil-Calcipotriene cream is a compounded drug and each ingredient is reviewed individually. Medicare Part D does not cover non-formulary drugs. The active ingredients within the compounded drug are not eligible for Part D coverage. Therefore, we determined the plan is not required to cover the Fluororacil-Calcipotriene cream or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tremfya 100 milligrams per milliliter prefilled syringe prescribed one at week zero, one at week four, and then every four weeks for psoriasis. 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 the doctor prescribed Tremfya to treat the enrollees unspecified psoriasis. 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 Tremfya.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira pen 40 milligrams/0.4 milliliter pen kit prescribed as directed. 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 included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.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 NP Thyroid 60 milligram tablet prescribed for an unknown diagnosis. The Part D plan denied your request. We performed and 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 NP Thyroid. NP Thyroid has not been approved by the Food and Drug Administration. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is 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

At issue is Silodosin 8 milligram capsule prescribed daily for benign prostatic hyperplasia and urinary retention. 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.  However, we did not receive the documentation.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. 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. A physician reviewed your appeal and determined that the plan is not required to cover Silodosin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Breo Ellipta 200-25 microgram inhalation powder prescribed for chronic obstructive pulmonary disease. 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 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. Breo Ellipta is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives included in the plan to treat the noted condition 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 coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Icatibant 30 milligram/3-milliliter syringe prescribed for acquired angioedema. 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 Icatibant to treat your acquired angioedema. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. In order to be covered Icatibant must be prescribed by, or in consultation with, an allergist/immunologist. Initial coverage is provided if you have documentation of specific lab values for C1-INH protein and C4 levels; these values assist in confirming your diagnosis. The documentation provided does show the enrollee has satisfied the plan's coverage criteria. A physician reviewed your appeal and determined that the plan is required to cover Icatibant.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Penicillin Vk 500 milligram tablet prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows you paid full price for the Penicillin VK at your pharmacy. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, documentation was provided showing the Medicare contracted price for the prescription was a portion of $2.66. The plan will only reimburse up to the contracted price of the drug. We determined the plan calculated reimbursement correctly and is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Timolol Maleate 0.5% eye drop solution prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows you paid full price for the Timolol Maleate at your pharmacy due to an error reflecting you had additional coverage. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, documentation was provided showing the Medicare contracted price for the prescription was a portion of $2.66. The plan will only reimburse up to the contracted price of the drug. We determined the plan calculated reimbursement correctly and is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stelara 130 milligrams per 26 milliliter prescribed intravenously for ulcerative rectosigmoiditis without complications. 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.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 medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.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 the appeal and determined that the plan is not required to cover Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Allzital 25-325 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. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Allzital has been prescribed for migraines.  A request was submitted to the prescriber to clarify the medical history, to address the nonformulary criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  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.  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 Febuxostat 40 milligram tablet prescribed for gout. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Febuxostat.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 145 microgram capsules prescribed daily. 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 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 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 Rybelsus 7 milligram tablet prescribed daily for type 2 diabetes mellitus with diabetic polyneuropathy. 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 all other drugs on the plans formulary would not work for you. A physician reviewed the appeal and determined that the plan is not required to cover Rybelsus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 40 milligram capsules prescribed as directed. 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. Vyvanse 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 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 request for coverage of Ropinirole Hydrochloride ER 25 milligram extended release tablets prescribed for restless leg syndrome. 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.Ropinirole Hydrochloride ER is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. During this review, a request was submitted to the prescriber to address the alternative medications included in the plans formulary and to provide supporting medical records. The prescriber did not respond to the request. Therefore, an exception to the plans 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 a request for coverage of Topiramate ER 200 milligram capsules prescribed for chronic migraine without aura. 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 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. Topiramate ER is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives included in the plan to treat the enrollees condition 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 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 a tiering exception request for Itraconazole 100 milligram capsules. The Part D plan denied the request stating that the drug was being used for a non-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. The medical records submitted at reconsideration indicate that Itraconazole has been prescribed for the treatment of disseminated histoplasmosis, which is a medically accepted indication outlined in the Medicare approved compendia. Itraconazole is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to cover Itraconazole at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha SureClick 140 milligrams per milliliter prescribed every 14 days for atherosclerotic heart disease of native coronary artery with unspecified angina pectoris and chronic total occlusion of coronary artery. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The records show the doctor prescribed Repatha SureClick to treat the enrollees atherosclerotic heart disease of native coronary artery with unspecified angina pectoris and chronic total occlusion of coronary artery. The 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 the appeal and determined that the plan is not required to cover Repatha SureClick. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.