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

You requested Atorvastatin 40 milligram tablet prescribed twice daily 180 tablets for 90 days for hyperlipidemia. 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 asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this amount of the medication. The documentation shows Atorvastatin was prescribed to treat hyperlipidemia. However, documentation was not received to  support why an exception to the plans quantity limit is medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover Atorvastatin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Imbruvica 280 milligram tablet prescribed daily for Waldenstrom macroglobulinemia. 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 records submitted at the reconsideration level.The medical records show the doctor prescribed Imbruvica to treat the enrollees Waldenstrom macroglobulinemia.The medical records do not support the diagnosis of Waldenstrom macroglobulinemia and support monoclonal antibody of unknown significance. Per the Medicare approved compendia, this is not a medically accepted indication. The documentation provided shows the enrollee has not satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Imbruvica.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pliaglis cream 7-7 percent prescribed as directed for radiculopathy, lumbar region, spinal stenosis, lumbar region with neurogenic claudication, bilateral primary osteoarthritis of knee, and post herpatic neuralgia. 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 Pliaglis to treat your radiculopathy, lumbar region, spinal stenosis, lumbar region with neurogenic claudication, bilateral primary osteoarthritis of knee, and post herpatic neuralgia. 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 Pliaglis.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 5 milligram capsules prescribed as directed for drug-induced 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 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. The documentation shows your doctor prescribed Dronabinol to treat your drug-induced constipation. 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

At issue is Xiidra 5% ophthalmic solution prescribed for sicca syndrome with keratoconjunctivitis. 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Xiidra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gamunex-C 10 gram/100 milliliter vial was prescribed to treat small fiber 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 prescriber statement shows Gamunex-C was prescribed to treat small fiber neuropathy. However, the Medicare approved compendia do not support the use of this drug for the condition. A physician reviewed your appeal and determined that the plan is not required to Gamunex-C.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Belladonna-Opium 16.2-60 milligram rectal suppository prescribed for the treatment of pelvic pain and bladder spasms. 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

At issue is Victoza 2 pak 18 milligram/ 3 milliliter pen prescribed for Type 2 diabetes mellitus without complications. 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. 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 prescriber indicates that Metformin had been tried and failed but no indication why all the other drugs on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Victoza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisolone Acetate 1% ophthalmic suspension prescribed to treat choroidal hemorrhage of the right eye. The Part D plan denied the appeal 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.Prednisolone Acetate is a generic drug on Tier 3 of the plans formulary. The doctor did not address why the drugs available on the lower tiers of the plans formulary would not work for the enrollee. Therefore, Prednisolone Acetate 1% ophthalmic suspension 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 Atomoxetine 40 milligram capsule prescribed twice daily for intermittent explosive disorder and conductive disorder-childhood onset. 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 records submitted at the reconsideration level.The doctor prescribed Atomoxetine 40 milligram capsule to treat the enrollees intermittent explosive disorder and conductive disorder-childhood onset. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed the appeal and determined that the plan is not required to cover Atomoxetine 40 milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Nystatin 100,000 unit per gram topical powder. 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. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Nystatin powder has been prescribed for the treatment of moisture-associated dermatitis. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha SureClick 140 milligram/milliliter pen injector prescribed as directed for primary hyperlipidemia with heterozygous familial hypercholesterolemia. 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 Repatha SureClick to treat your primary hyperlipidemia with heterozygous familial hypercholesterolemia. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle Libre 2 Sensor prescribed as directed. 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 you requested coverage for Freestyle Libre 2 Sensor. However, this product may be eligible for coverage under Medicare Part B. Medicare rules state drugs and medical supplies not directly associated with the injection of insulin are not covered under Part D. 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.We determined that the plan is not required to cover Freestyle Libre 2 Sensor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myfortic 360 milligram delayed release tablet prescribed for suspected seronegative neuromyelitis optica spectrum disorder vs. an unspecified immune mediated recurrent optic neuritis. The Part D plan denied the request.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. The prescriber indicates the Myfortic 360 milligram delayed release tablet is prescribed for suspected seronegative neuromyelitis optica spectrum disorder vs. an unspecified immune mediated recurrent optic neuritis. 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 Myfortic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carbidopa-Levadopa 50-200 extended release tablet. 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. Carbidopa-Levadopa 50-200 extended release 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 your condition have been tried or deemed contraindicated. 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 Sancuso 3.1-milligram/24-Hour Patch to treat nausea and vomiting due to chemotherapy. 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. This medication is not on your plan's list of medications. The prescriber has not given a clear and valid medical reason why all medications required by the plan, on that list, did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. Therefore, an exception to the plans formulary coverage criteria is not supported. A physician reviewed your appeal and determined that the plan is not required to cover Sancuso 3.1-milligram/24-Hour Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 50 milligram capsule prescribed for cervical radiculopathy and cervical post-laminectomy pain syndrome. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. The prescriber indicates that Pregabalin 50 milligram capsule is prescribed for an enrollee with cervical radiculopathy and post-laminectomy pain with numbness and tingling radiating down both arms. 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 Pregabalin.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Sildenafil Citrate 20 milligram tablets. The Part D plan denied the request because there was insufficient documentation to determine if the plans prior authorization requirements were met.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. During this review, a prescriber statement of medical necessity and supporting medical records were requested from the prescriber. The prescriber responded and submitted the requested documentation.The newly submitted medical records indicate that Sildenafil Citrate had been prescribed for the treatment of pulmonary arterial hypertension, World Health Organization (WHO) Group 1, which is a medically accepted indication for Sildenafil Citrate, as outlined in the Medicare approved compendia. The medical records support that the enrollee was diagnosed with pulmonary arterial hypertension by right heart catheterization on May 18, 2010. The prescriber has noted that this is a continuation of therapy, as the enrollee has been taking Sildenafil Citrate since 2011. It is noted in the prescriber statement that the enrollee has been stable on Sildenafil Citrate 20 milligram tablets, three times daily with good therapeutic effect. Therefore, the newly submitted documentation supports that the plans requirements for renewal of Sildenafil Citrate therapy have been met. The plans quantity limit for this drug is 90 tablets per 30 days, which is what has been requested by the prescriber.  In summary, the documentation supports that the medication is being used for a medically accepted indication, the plans reauthorization requirements have been met, and the quantity limit has not been exceeded. Therefore, coverage for the drug can be allowed. A physician reviewed the appeal and determined that the plan is required to cover the Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lamotrigine 100 milligram orally disintegrating tablet prescribed two tablets daily for Lewy body dementia. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The doctor prescribed Lamotrigine for the enrollees Lewy body dementia. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Lamotrigine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xiidra 5% dropperette prescribed for dry eye 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 records submitted at the reconsideration level. The medical records show Xiidra was prescribed to treat dry eye syndrome. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Xiidra. 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

At issue is Tacrolimus 1 milligram capsules prescribed daily following a kidney transplant. 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. We also researched Medicare systems and reviewed the enrollment data available. Based on the information provided, the drug is eligible for Part B coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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: Favorable

You requested Lenvima 20 milligram tablets prescribed for metastatic melanoma. 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 submitted documentation supports the physician prescribed Lenvima in combination with Keytruda for metastatic melanoma. The Medicare approved compendium indicates the drug at issue is labelled an orphan drug to treat stage II-IV metastatic melanoma. Furthermore, the appellant submitted a Medicare approved journal article to support the use of Lenvima in combination with Keytruda for the enrollees condition. A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mesalamine Delayed Release 1.2-gram tablet prescribed ulcerative colitis. 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.Mesalamine Delayed Release is a generic drug on Tier 4 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat your condition have been tried or deemed contraindicated. 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 Cyproheptadine Hydrochloride 4 milligram tablet prescribed to stimulate appetite. 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 Medicare approved compendia. The prescriber indicates the enrollee resides in a long term care facility and has lost weight due to refusal to eat and take medications due to dementia and other medical conditions. Medications used for anorexia, weight loss, or weight gain are excluded from Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Cyproheptadine Hydrochloride.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Budesonide 0.5 milligrams per 2 milliliter prescribed four milliliters twice daily by mouth for eosinophilic esophagitis. 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 determined that the drug is not eligible for Part B coverage. The drug is not being administered via nebulizer. Therefore, the drug can be considered for payment under the Part D benefit.The doctor prescribed Budesonide respules suspension to treat the enrollees eosinophilic esophagitis. The following citation was referenced in the American Hospital Formulary Service Drug Information, a Medicare approved compendia, and supports the use of this drug for your condition: Data from controlled trials and meta-analyses indicate that budesonide inhalational suspension, compounded into a viscous suspension and swallowed rather than inhaled, is effective at improving the clinicopathologic features of eosinophilic esophagitis.A physician reviewed your appeal and determined that the plan is required to cover Budesonide.