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

You requested Chlordiazepoxide-Clidinium 5 milligram-2.5 milligram capsules prescribed for irritable bowel syndrome. 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 record shows the drug at issue is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover the drug at issue. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick solution auto-injector 140 milligrams/milliliter prescribed for coronary atherosclerosis and hyperlipidemia. 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 Repatha Sureclick for your coronary atherosclerosis and hyperlipidemia. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Actemra 162 milligram per 0.9 milliliter auto-injector. 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.At initial determination the diagnosis of unspecified chorioretinal inflammation, bilateral and refractory retinal vasculitis was given. At redetermination the physician submitted a supporting statement and medical records that show Actemra was prescribed to treat birdshot chorioretinitis with severe uveitic macular edema and retinal vasculitis. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed your appeal and determined that the plan is not required to cover Actemra.
Appeal type: Prescription Drug
Decision: Favorable

You requested Prolia (Denosumab) 60 milligram/milliliter injection prescribed for related osteoporosis without current pathological fracture. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The documentation supports your doctor prescribed Prolia to treat your related osteoporosis without current pathological fracture. The following citation was referenced in the American Hospital Formulary Service Drug Information, a Medicare approved compendium, and supports the use of this drug for your condition: Denosumab is used in the treatment of osteoporosis in postmenopausal women at high risk for fracture, defined as a history of osteoporotic fracture or multiple risk factors for fracture. Denosumab also is used in the treatment of osteoporosis in postmenopausal women following failure of or intolerance to other osteoporosis therapies.The physician has stated that you have tried Fosamax and Actonel but had adverse effects. In addition, a high risk for fracture is defined as a T score less than -2.5. A physician reviewed your appeal and determined that the plan is required to cover Prolia. Prolia is used in women with postmenopausal women with intolerance to other osteoporosis therapies. In addition, your T scores support the diagnosis of a high risk of fracture. Therefore, the prior authorization requirements have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Xolair 150 milligram solution. 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 Xolair to treat your allergic asthma. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Xolair. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You Lidocaine 5% patch prescribed for chronic bilateral back pain with bilateral sciatica and idiopathic peripheral neuropathy. 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 Lidocaine 5% patch for your chronic bilateral back pain with bilateral sciatica and idiopathic peripheral neuropathy. 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Memantine HCL 5 milligram tablets prescribed to treat amnesia. 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 Memantine HCL 5 milligram tablets to treat amnesia. The prescribers statement includes the diagnosis of dementia. DRUGDEX shows dementia is listed as a non-Federal Drug Administration use for the requested drug. However, no medical records were provided to support the diagnosis of dementia. Therefore, 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 Memantine HCL 5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Livalo 2 milligram tablets prescribed for atherosclerotic heart disease of native coronary artery. 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 did not include medical records or a supporting statement. A request for information was sent to the prescriber; however, no further records were received. There is no supporting documentation to indicate that the enrollee has a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Livalo.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Vraylar 1.5 milligram tablet prescribed daily for bipolar disorder. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your medical records show your doctor prescribed Vraylar to treat your bipolar disorder. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided supports the enrollee has satisfied the plan's coverage criteria.  In the Reconsideration appeal the prescriber submitted additional medical records.  The medical records submitted support that the enrollee has tried Aripiprazole, Quetiapine, and Risperidone.A physician reviewed your appeal and determined that the plan is required to cover Vraylar.  The prior authorization requirements have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Afinitor 10 milligram tablets prescribed for the treatment of castrate resistant metastatic prostate cancer.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  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.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Praluent solution auto-injector 75 milligrams/milliliter prescribed for an enrollee with hyperlipidemia and coronary artery disease.  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.  In the Reconsideration appeal the prescriber submitted supporting medical records and laboratory reports.  The documentation satisfies the plans coverage criteria.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 1 percent gel prescribed as directed for other intervertebral disc degeneration, lumbar region, spondylosis, unspecified, and other specified arthritis, unspecified site. 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 Diclofenac Sodium 1 percent gel to treat your intervertebral disc degeneration, lumbar region, spondylosis, unspecified, and other specified arthritis, unspecified site. 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 Diclofenac Sodium 1 percent gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tolterodine Tartrate extended release capsule 24 hour 4 milligram. At initial determination and redetermination the diagnosis of stress incontinence was given. The Part D plan denied the request stating that the provided diagnosis is 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.At reconsideration level a diagnosis of overactive bladder was given. We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need this medication. We did not receive the documentation requested. Specifically, no medical records were provided in the case for review. 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 your appeal and determined that the plan is not required to cover Tolterodine Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epclusa 400 milligram/100 milligram tablets prescribed as directed for hepatitis C, genotype two. 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 Epclusa to treat your hepatitis C, genotype two. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Epclusa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dexilant 60 milligram tablets 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. Dexilant is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lovaza 1 gram 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. Lovaza is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Singulair 10 milligram tablets 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. We asked your prescriber to send us information about 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 similar medications on the lower teirs would not work for you. . However, we did not receive the documentation.Singulair is a brand drug on Tier 3 of the plans formulary. Your doctor did not address why 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: Unfavorable

At issue is Trulicity 0.75 milligram/0.5 milliliter pen injector 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. Trulicity is a biological product drug on Tier 3 of the plans formulary. There are no biological product drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is OmniPod 5 pack prescribed as directed for diabetes management. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.Your medical records show your doctor prescribed OmniPod to treat your diabetes management. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover OmniPod 5 pack.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Praluent 150 milligram pen to treat hyperlipidemia with a history of atherosclerotic cardiovascular disease.   The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mycophenolate Mofetil 250-milligram capsule to treat kidney transplant rejection. 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 prescriber was asked to address the prior authorization criteria.   The date of the transplant was 8/30/2018.  The enrollee's Medicare Part B became active on 3/1/2019.  The documentation satisfies the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Belladonna-Opium 60-16.2 milligram rectal suppository, 12 per 30 days prescribed for unknown diagnosis. 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. According to Medicare rules, drugs that are not approved by the Food and Drug Administration are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Belladonna-Opium suppository. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested SM Senna laxative 8.6 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. 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 the SM Senna because this drug is excluded from coverage under Medicare Part D. According to the Food and Drug Administration, SM Senna is a non-prescription or over the counter drug not eligible for Part D coverage. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vancomycin HCL 250 milligram capsule, a quantity of 90 capsules for 90 days for recurrent clostridium difficile 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need this medication. We did not receive the documentation requested.. Your doctor prescribed Vancomycin HCL to prevent recurrent clostridium difficile colitis. However, the Medicare approved compendia do not support the use of this drug for prevention of clostridium difficile colitis.A physician reviewed your appeal and determined that the plan is not required to cover Vancomycin HCL.