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

You requested coverage for Forteo 620 microgram per 2.48 milliliter subcutaneous injection pen prescribed for post-menopausal osteoporosis. 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 does not satisfy the plans prior authorization requirements. The prescriber has addressed the authorization criteria; however, the responses do not satisfy all of the plans requirements for coverage of this medication. 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 Pantoprazole Sodium 40 milligram delayed release suspension packets prescribed for eosinophilic esophagitis and dysphagia. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. 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. 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 Pantoprazole Sodium. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Eliquis 5 milligram tablets prescribed for atrial tachycardia. The Part D plan denied your request for a tiering exception because Eliquis 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 Eliquis 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 Dupixent 300 milligrams/2 milliliters prescribed for asthma. 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 for information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We received the documentation and included it in our review.The records show Dupixent was prescribed to treat the enrollees asthma. The Medicare approved compendia do support the use of this biologic for this condition. However, the plan requires prior authorization criteria be met before they will cover the requested biologic. 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 Dupixent 300 milligrams/2 milliliters.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% ointment to treat the enrollees condition. 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.Lidocaine 5% ointment is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain 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 coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20-milligram tablet to treat pulmonary hypertension. 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.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 Gattex 5 milligram kit. 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 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The prescriber statement and medical records show your doctor prescribed Gattex to treat your short bowel syndrome with associated chronic malabsorption disorder. The Medicare approved compendia do not support the use of this drug for your condition. The following citation was referenced in DrugDex, a Medicare approved compendium, and shows the drug is indicated for the condition of small bowel syndrome dependent on parenteral support.As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Gattex.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 0.1% ointment prescribed to treat dense lichenoid interface dermatitis associated with lupus. 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 also researched Medicare regulations and Medicare approved compendia. The Medicare approved compendia does not support the use of the drug for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Tacrolimus ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine-Dextroamphetamine 10 milligram capsules. 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 contain a supporting statement or medical records to indicate a prescribed diagnosis. A request for records was sent to your doctor; however, no further documentation was received. 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 Gammagard Liquid 10% at 45 grams daily prescribed to treat myopathy. 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 also researched Medicare regulations and Medicare approved compendia. The prescriber indicates the enrollee has myopathy and polymyositis. The medical records support a diagnosis of myopathy, unspecified. The Medicare approved compendia do not support the use of the drug for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Gammagard Liquid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mesalamine DR 400 milligram capsules prescribed twice daily for ulcerative colitis. 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 prescriber has not indicated 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Mesalamine DR.A physician reviewed your appeal and determined that the plan is not required to cover the Mesalamine DR.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Mycophenolate Sodium 360 milligram delayed release 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 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 also researched Medicare systems and reviewed the enrollment data available.The documentation indicates the Mycophenolate Sodium has been prescribed for transplant rejection prophylaxis following a lung transplant. The documentation supports that the enrollee underwent the lung transplant on June 16, 2017. Medicare records show that the enrollees Medicare A benefit effective date was October 1, 2017. Therefore, the documentation supports that the transplant was not covered under Medicare Part A. Subsequently, coverage for the Mycophenolate Sodium should be coverable under the Medicare Part D benefit if being prescribed for a medically accepted indication.The American Hospital Formulary Service Drug Information (AFHS-DI) has a positive citation:  Mycophenolate Mofetil and Mycophenolate Sodium have been used for the prevention of rejection of lung allografts in patients who have undergone lung transplantation. Following lung transplantation, acute allograft rejection and chronic lung allograft dysfunction, including bronchiolitis obliterans syndrome, are major complications affecting long-term graft and patient survival. Several clinical trials and clinical experience to date indicate that Mycophenolate used in combination with other immunosuppressants is effective in the prevention of allograft rejection following lung transplantation.During this review a prescriber statement and supporting medical records were requested from the prescribing physician to validate that the enrollee is taking Mycophenolate Sodium in combination with other immunosuppressants to prevent allograft rejection following lung transplantation. However, the prescribing physician did not submit a prescriber statement or any supporting medical records. Without any supporting documentation from the prescribing physician, it is not possible to validate if the medication is being prescribed for a medically accepted indication, as outlined in the Medicare approved compendia. 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 Taltz 80 milligrams/milliliter auto-injector prescribed as directed for pityriasis rubra pilaris. 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 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 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 Taltz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Ozempic 2 milligram per milliliter subcutaneous injection pen prescribed for type 2 diabetes with hyperglycemia. The Part D plan forwarded the request for us to review. We received the case to perform an independent and de novo review. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. The Part D plan has a step therapy requirement for coverage of Ozempic. This means that the enrollee must first try one of the following: Byetta, Bydureon, or Trulicity before coverage for Ozempic will be approved. During this review, a prescriber statement and supporting medical records were requested from the prescribing physician to address this requirement. However, the prescribing physician did not respond to the request.Therefore, it is not possible to determine if the plans step therapy requirement has been met for the medication. A physician reviewed your appeal and determined that the plan is not required to cover the Ozempic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Emgality 120 milligram per milliliter auto injector solution prescribed for chronic migraines. 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.This drug is being 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz XR 11 milligram tablet to treat systemic lupus erythematosus and tenosynovitis. 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: Unfavorable

At issue is Jardiance 10 milligram tablet prescribed for type II diabetes. The plan did not make a decision within the required timeframe. The case was auto-forwarded by the plan. 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.Jardiance is a brand name drug on Tier 3 of the plans formulary. There are no brand name drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception. There are no lower tiered brand drugs of the same type to treat your condition.A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dafampridine Extended Release 10 milligram tablets prescribed to treat a walking disability in an enrollee with multiple sclerosis. 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. We also researched Medicare regulations and Medicare approved compendia. The plan requires prior authorization requirements be met before covering this drug. The documentation submitted does not include medical records supporting the diagnosis or walking ability of the enrollee. We requested medical records from the prescriber but did not receive a response. A physician reviewed your appeal and determined that the plan is not required to cover Dafampridine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sunosi 75 milligram tablet to treat daytime somnolence secondary to Parkinson's 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 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 Testosterone 1.62% gel prescribed as directed to treat hypogonadism. The Part D plan denied the 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 the Testosterone gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Entresto 24/26 milligram tablets prescribed for left ventricular dysfunction with ejection fraction of 35 percent. The Part D plan denied your request for a tiering exception because Entresto 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 Entresto 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

You requested Perforomist 20 microgram/2-milliliter solution prescribed daily for chronic obstructive pulmonary disease. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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. The record shows that your doctor prescribed Perforomist to treat chronic obstructive pulmonary disease. Medicare records indicate you were not covered under Part A for your stay at the skilled nursing facility. Therefore, Perforomist is covered under Medicare Part D. As such, our decision is that the Part D plan is required to cover Perforomist.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Fioricet 50-300-40 milligram capsules prescribed as directed for headaches. 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 prescriber has not indicated 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Fioricet.A physician reviewed your appeal and determined that the plan is not required to cover the Fioricet.
Appeal type: Prescription Drug
Decision: Favorable

You requested Restasis 0.05% Ophthalmic Eye Drops for dry eye syndrome (keratoconjunctivitis sicca). 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 regulations and Medicare approved compendia.The record shows you were prescribed Restasis 0.05% Ophthalmic Eye Drops for dry eye syndrome. The following citation in Lexicomp, American Hospital Formulary System-Drug Information, Adult and Pediatric a Medicare approved compendium, supports the use of the requested drug for your condition stating, The recommended dosage of cyclosporine in the management of keratoconjunctivitis sicca in adults is one drop of a 0.05% emulsion in each eye twice daily, administered approximately 12 hours apart. Therefore, it is considered a medically accepted indication.Our physician reviewer determined that the requested drug is eligible for Part D coverage.