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

At issue is Vraylar 1.5 milligram capsules prescribed for alcohol abuse in remission, generalized anxiety disorder, and mild cognitive impairment. 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 Vraylar is prescribed for alcohol abuse in remission, generalized anxiety disorder, and mild cognitive impairment. 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 Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patches prescribed for left flank pain following a lung transplant. 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 Lidocaine 5% patches for left flank pain following a lung transplant. Your doctor submitted a statement to indicate the diagnosis should be chest wall pain. The Medicare approved compendia do not support the use of the drug at issue for your condition. 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 Vyndamax 61 milligram tablets prescribed daily for wild-type transthyretin-related amyloidosis. 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 Vyndaqel would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Vyndamax.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cimzia 2x200 milligrams syringe kit prescribed to treat Behcets 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 Cimzia 2x200 milligrams syringe kit to treat Behcets disease. Cimzia is not on the plans formulary. 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 Cimzia 2x200 milligrams syringe kit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram prescribed Addisons disease and short gut syndrome. 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 Dronabinol for Addisons disease and short gut syndrome. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dupixent 300 milligram/2-milliliter syringe prescribed for bullous pemphigoid. The Part D plan denied the request as a non-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. We also researched Medicare regulations and Medicare approved compendia.At reconsideration, Dupixent 300 milligram/2-milliliter syringe was prescribed for bullous pemphigoid. The Medicare approved compendia, and the FDA, list this drug as an orphan drug for the medical condition in this enrollee. Therefore, it is considered a medically accepted indication.The documentation, however, does not satisfy the plans non-formulary exception criteria. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan, to treat this 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 formulary coverage criteria is not supported. Our physician reviewer's opinion is that the non-formulary drug exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine HCL urethral/mucosal 2% gel prescribed to treat the enrollee's 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

You requested Ibrance 125 milligram tablets prescribed for metastatic hormone receptor positive breast cancer. 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 Ibrance 125 milligram tablet to treat the enrollees metastatic hormone receptor positive breast cancer. It is noted that there is a discrepancy in the medical records submitted regarding the enrollees human epidermal growth factor receptor 2 status. Therefore, the Medicare approved compendia and Medicare approved journals 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 Ibrance 125 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Incruse Ellipta 62.5 microgram blister with inhalation device 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. Incruse 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

You requested Calcipotriene 0.005% cream prescribed for confluent and reticulated papillomatosis. 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 Calcipotriene 0.005% cream to treat the enrollees confluent and reticulated papillomatosis. 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 Calcipotriene 0.005% cream.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tetrabenazine 12.5 milligram tablets prescribed for extrapyramidal and movement disorder, unspecified. 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 Tetrabenazine for extrapyramidal and movement disorder, unspecified. 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 Taltz Autoinjector 80 milligram/milliliter prescribed to treat psoriatic arthritis. 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 prescriber indicates you had tried Embrel but it was too expensive. The prescriber submitted a list of medications tried in the past which includes Humira but no reason or medical records showing why that was discontinued. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The enrollee has not satisfied the plan's coverage criteria. A physician reviewed your appeal and determined that the plan is not required to cover Talz. 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: Favorable

At issue is Trulance 3 milligram tablet prescribed for chronic idiopathic constipation. 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 medical records submitted now include a progress note date May 17, 2021. The progress note indicates that you prescribed Trulance 3 milligram tablet to treat the enrollees chronic idiopathic constipation. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided now shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Trulance 3 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Colesevelam Hydrochloride 625 milligram tablets prescribed for collagenous colitis. 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. We also researched Medicare regulations and reviewed the enrollment data available. The documentation shows you were prescribed Colesevelam Hydrochloride 625 milligram tablets to treat collagenous colitis. 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 Colesevelam Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine-Prilocaine Cream prescribed for use during dialysis. 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. The record shows the drug is being used as a local anesthetic during kidney dialysis. However, this drug may be eligible for coverage under Medicare Part B. All drugs  used for the treatment of end-stage kidney disease are included in a bundled payment under the medical benefit to the dialysis facility and are not separately paid.We determined that the plan is not required to reimburse Lidocaine-Prilocaine Cream.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil 20 milligram tablets prescribed for pulmonary hypertension, group II and group I out of proportion. 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 Sildenafil for pulmonary hypertension, group II and group I out of proportion. The medical records submitted indicate a diagnosis of pulmonary hypertension, group II and group III out of proportion. 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

You requested Hydroxyzine Hydrochloride 50 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. 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. We did not receive the documentation requested.At initial determination the diagnosis of right shoulder pain with associated primary osteoarthritis of the right shoulder was given. At redetermination, the prescriber statement shows Hydroxyzine Hydrochloride was prescribed to treat pruritus.  Medical records were requested.  However, no medical records were submitted to support this diagnosis.  Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Hydroxyzine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets to treat your condition. 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. We did not receive the requested documentation.Xifaxan 550 milligram tablets was prescribed to treat your condition. The plan denied your request because the prior authorization requirements were not met. However, there was no documented diagnosis or medical records submitted supporting your condition. The QIC is unable to determine if your condition is a medically-accepted indication to support the use of the requested drug.A physician reviewed your appeal and determined that the plan is not required to cover Xifaxan 550 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gammaked Solution 10 gram/100 milligram prescribed for other inflammatory neuropathies. 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 Gammaked Solution is prescribed for other inflammatory neuropathies. 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 Gammaked Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 20 milligram tablet prescribed daily for recurrent major depressive 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 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.At reconsideration a diagnosis of bipolar disorder was given. However, there were no medical records provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the plan is not required to cover Latuda.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcitriol 0.25 microgram capsules prescribed for vitamin D deficiency in an enrollee with chronic kidney disease. The Part D plan denied your request indicating Medicare Part B pays for drugs used for treatment of end-stage renal disease when on dialysis.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 documentation submitted shows the enrollee is not receiving or requiring dialysis. Therefore, the drug is eligible for Part D drug benefits. 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 Calcitriol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sirolimus 0.5 milligram tablets. 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. Sirolimus is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why all of the drugs available on the lower tiers of your plans formulary would not work for you. 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: Favorable

You requested Braftovi 75 milligram capsules prescribed as directed for metastatic melanoma. 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 physician prescribed Braftovi, in combination with Mektovi, to treat metastatic melanoma. The enrollee was found to have a nasal melanoma with BRAF mutation. The enrollee was treated with Keytruda, but imaging results from May 2021, showed frank progression of the disease after four cycles of treatment. The enrollee developed new lesions on the back and liver, as well as possible bony lesions. Additionally, the enrollee developed new gum lesions and the nasal lesion was enlarging. Since Keytruda was not beneficial for this enrollee, the physicians treatment plan includes discontinuation of Keytruda. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Encorafenib is indicated, in combination with Binimetinib, for the treatment of adults with unresectable or metastatic melanoma with a BRAF V600E or V600K mutation. Furthermore, the documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Braftovi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buproprion Hydrochloride ER 24 HR 300 milligram tablet prescribed daily for depression. 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 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 the prescriber to send us information about 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 similar medications on the lower tiers would not work. We received the documentation and included it in our review.Buproprion Hydrochloride ER 24 HR 300 milligram tablet is a generic drug on Tier 3 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat the enrollees condition have been tried or deemed contraindicated. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lipitor 10 milligram tablets.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. Your prescriber indicates you cannot tolerate Crestor and are tolerating Lipitor 10 milligrams. We requested additional information from your prescriber but did not receive a response. The information was insufficient to determine if the drug is medically indicated for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Lipitor.