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

At issue is Sandostatin LAR Depot injection to treat postsurgical malabsorption, diarrhea secondary to short bowel 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. At reconsideration, clarification of the clinical scenario was provided, supported by medical records. The enrollee has ileostomy associated diarrhea, a type of short gut syndrome. Micromedex, a Medicare approved compendia, contains a positive citation, Octreotide has been used successfully to treat persistent ileostomy diarrhea in adults. It is therefore an off-label medically accepted indication.However, this is a non-formulary drug, and 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. Formulary alternatives could include Tegulutide, antimotility agents, antisecretory agents and glucocorticoids. These alternatives are discussed in Ileostomy diarrhea: Pathophysiology and management - Proc (Bayl Univ Med Cent). 2020 Apr; 33(2): 218226. A physician reviewed your appeal and determined that the plan is not required to cover Sandostatin LAR Depot injection.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil citrate 100 milligram tablets prescribed for erectile dysfunction. 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. We determined that the plan is not required to cover Sildenafil citrate. According to your plans Evidence of Coverage, drugs prescribed to treat sexual/erectile dysfunction are excluded from coverage under Medicare Part D. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested DexCom G6 Transmitter prescribed for diabetes mellitus. 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 item at issue is for the monitoring of glucose. This is eligible for coverage under Part B. The item is not eligible for Part D coverage.We determined that the plan is not required to cover DexCom G6 Transmitter.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested an oxygen concentrator. The Part D plan denied the request. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.We determined that the plan is not required to the oxygen concentrator because it is eligible for coverage under Medicare Durable Medical Equipment. Medicare Part D does not cover Durable Medical Equipment. 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 Guanfacine ER 1 milligram tablet to treat attention deficit hyperactivity disorder, combined type. 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 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Myrbetriq ER 50 milligram tablets prescribed daily for urge incontinence. 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. Myrbetriq ER is a brand drug on Tier 3 of the plans formulary. The prescriber statement indicates the enrollee has tried and failed other medication, and anticholinergics are not safe for the enrollee. There are no brand drugs of the same type on the lower cost sharing tiers of the plans formulary. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 2 milligram sublingual tablets prescribed for your chronic pain. 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 an expedited 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. The documentation supports the drug was prescribed for your chronic pain. The Medicare approved compendia does not support the use of this drug for your condition. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Ruconest 2100 units prescribed for hereditary angioedema with C1 inhibitor deficiency. The Part D plan denied coverage because medical necessity was not established.  We received an expedited 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. The submitted documentation indicates a history of recurrent facial and mucosa swelling, as well as a significantly decreased C4 and C1 esterase inhibitor level. Therefore, the diagnosis of hereditary angioedema with C1 inhibitor deficiency is supported.  The following citation in the Journal of Allergy and Clinical Immunology, a Medicare approved compendium, supports the use of the requested drug for your condition:  In a randomized study of patients 6 to 72 years old with acute abdominal or facial attacks who received C1 inhibitor concentrate achieved a significant decrease in time to onset of symptom relief compared with patients who received placebo.  Therefore, it is considered a medically accepted indication.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydroxyzine Hydrochloride 10 milligram tablets prescribed for severe pruritus. 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 some documentation and included it in our review.The records show you prescribed Hydroxyzine Hydrochloride 10 milligram tablets to treat the enrollees pruritus. The Medicare approved compendia do support the use of this drug for your condition. The plan requires prior authorization criteria be met before they will cover the requested drug. The documentation does not satisfy the plans coverage criteria. Medical records were requested but were not provided. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine HCL 20 milligram tablet to treat anxiety. 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 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 Hydroxyzine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ofev 150 milligram oral capsule prescribed daily for other interstitial pulmonary disease with fibrosis classified elsewhere. The Part D plan denied your request. 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 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 and redetermination the diagnosis of other interstitial pulmonary disease with fibrosis classified elsewhere was given. At reconsideration the diagnosis of progressive fibrosing interstitial lung disease was given. However, no medical records were provided to support either diagnosis. It cannot be determined if the requested drug was prescribed for a medically accepted indication. As such, 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 Ofev.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Micardis 40 milligram tablet to treat 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.A request was submitted to the prescriber to provide a diagnosis, to address the formulary exception 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.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Voriconazole 200 milligram tablets. 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 the case file carefully. During this review, a prescriber statement was requested and received. We reviewed all documentation submitted.The documentation submitted to the plan indicates that Voriconazole was prescribed to treat entrocolitis due to Clostridium difficile, which is not a medically accepted indication for the use of Voriconazole.However, at reconsideration, it has been noted that the diagnosis of entrocolitis due to Clostridium difficile was given to the plan in error by the prescribers office staff. While the enrollee does have a history of Clostridium difficile infection, it is noted that the enrollee, who is currently receiving therapy for metastatic lung cancer, is receiving Voriconazole prophylactically due to a history of invasive Aspergillosis fungal infection of the lungs. Medical records have been submitted at reconsideration that verify the enrollee was hospitalized with an invasive Aspergillosis fungal pneumonia in December 2016 and received Voriconazole. As outlined in the Medicare approved compendia, invasive Aspergillosis prophylaxis while receiving chemotherapy is a medically accepted use for Voriconazole.The plans prior authorization requirements for Voriconazole are that the medication is being used for a Food and Drug Administration-approved indication and the medication will be taken orally or intravenously. The documentation supports that the enrollee is using the medication for a Food and Drug Administration-approved indication and will be taking the medication orally. Therefore, the medical records submitted at reconsideration validate that the Voriconazole is being used for a medically accepted indication and that the plans prior authorization requirements for coverage of the drug have been satisfied. A physician reviewed the appeal and determined that the plan is required to cover the Voriconazole.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tadalafil 5 milligram tablets prescribed as directed. 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 medical records and a supporting statement showing the need for Tadalafil. However, we did not receive the documentation.The documentation available for review does not include medical records. 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 Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone gel 1.62% to treat testicular hypo-function.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The Medicare approved compendia, DrugDex, states that Testosterone is used to treat, Male Hypogonadism. The diagnosis is therefore a medically accepted indication. The documentation however does not satisfy the plans coverage (prior authorization) criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the provided medical records do not satisfy the coverage criteria.  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 Testosterone Enanthate 200 milligram/milliliter solution to treat Hypotestosteronism.   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 provided addressed the plans coverage criteria, and those criteria were not satisfied.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed for circadian rhythm sleep disorder, free running type. The Part D plan denied coverage.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. The documentation submitted does not support that you satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed for radiculopathy of lumbar region, chronic pain syndrome, and chronic muscle spasms. 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 Cyclobenzaprine Hydrochloride for radiculopathy of lumbar region, chronic pain syndrome, and chronic muscle spasms.  The prescriber stated that the enrollee has been taking the requested drug since 2015.  The Medicare approved compendia do not support the use of this drug 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 a tiering exception request for Chlorthalidone 25 milligram tablet to treat the enrollees condition. 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.Chlorthalidone is a generic drug on Tier 3 of the plans formulary. Your doctor submitted medical records. However, the plans formulary includes Furosemide tablets, Indapamide, Torsemide, Triamterene/Hydrochlorothiazide tablets, and capsules which are the same class as Chlorthalidone on Tiers 1 and 2 of the plans formulary. Your doctor did not address why these medications would not work for you. All generic drugs on lower tiers have not been tried. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Sirolimus 0.5 milligram tablets prescribed following a heart transplant. The Part D Plan forwarded you request to us for review. 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. During this review, a prescriber statement and supporting medical records were requested from your doctor. The doctor did not respond to our request.Sirolimus is a generic drug on Tier 4 of the plans formulary. The prescribing physician has not sufficiently addressed why the generic drugs of the same type on the lower tiers of the plans formulary to treat your condition have been tried and failed, or are contraindicated. A physician reviewed the appeal and determined that the plan is not required to grant a tiering exception to the Sirolimus at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omega 3-Acid Ethyl Esters 1 gram capsule to treat the enrollees condition. 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.A request was submitted to the prescriber to provide a diagnosis and supporting medical records. A reply was not received. Therefore, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 20 milligram tablets to treat the enrollees condition. 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.Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ongentys 50-milligram capsule to treat Parkinsons disease. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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.