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

At issue is Auryxia 210-milligram tablets prescribed for hyperphosphatemia in a patient with chronic kidney disease not on 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 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 submitted shows the prescriber ordered Auryxia to treat the enrollees condition of hyperphosphatemia in a patient with chronic kidney disease not on dialysis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Auryxia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed daily for chronic low back pain due to lumbar radiculitis, lumbar spondylosis, and sacroiliac joint dysfunction. 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 diagnoses. We also asked for medical records or other documentation to show why this medication was needed. We received the documentation and included it in our review.The documentation shows the doctor prescribed Lidocaine 5% patch to treat the enrollees chronic low back pain due to lumbar radiculitis, lumbar spondylosis, and sacroiliac joint dysfunction. However, the Medicare approved compendia do not support the use of this drug for these diagnoses.A physician reviewed the appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Verzenio 150-milligram tablets prescribed for the treatment of metastatic pancreatic cancer. 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 approved Medicare compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. The submitted documentation does not include any peer-reviewed, clinically relevant medical literature from an approved journal to support the use of this drug for the noted condition. Therefore, the requested drug is being prescribed for a non-medically accepted indication as defined by Medicare. As such, an exceptions request based on medical necessity cannot be considered because the requested drug does not meet the definition of a Medicare Part D drug. 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 a tiering exception request for Januvia 50-milligram tablets prescribed for the treatment of type 2 diabetes mellitus. 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.Januvia is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost-sharing tier. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level. The drug will continue to be covered at the Tier 3 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine Hydrochloride 25-milligram tablets prescribed for psoriasis. 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 documentation submitted shows the prescriber ordered Hydroxyzine Hydrochloride to treat the enrollees condition of psoriasis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Hydroxyzine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 1.5 mg capsules 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. This drug is included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.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 Dronabinol 10 milligram capsules prescribed as directed for anorexia. 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 to treat your anorexia related to chronic disease. 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 Cosentyx 150 milligram/milliliter pen injector prescribed as directed for active 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 medical records show your doctor prescribed Cosentyx to treat your active psoriatic arthritis. 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 Cosentyx.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is NP Thyroid 90 milligram and 15 milligram tablets to treat hypothyroidism. 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.NP Thyroid has no FDA approved medically accepted indications. Non-FDA approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.The plan is not required to cover this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 2.5 milligram tablets prescribed to treat the diagnosis of benign prostatic hyperplasia with urinary frequency. The Part D plan denied the appeal 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.We asked the prescriber to send us additional information regarding the enrollees condition. Specifically, we asked for the completion of the plans prior authorization documentation to show why the enrollee needs this medication. We did not receive the requested documentation.The documentation shows the doctor prescribed Tadalafil 2.5 milligram tablets to treat the enrollees condition. 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 Tadalafil 2.5 milligram tablets, as the plans prior authorization criteria has not been satisfied. 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 reimbursement for Naltrexone 4.5 milligram prescribed daily for chronic back pain and myotascial pain. 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 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 drug at issue was dispensed at a pharmacy not in the plans network on the date the prescription was filled. In these instances, the enrollee may be responsible for paying the difference between what they pay for the drug at the out of network pharmacy and the cost that the plan would cover at an in network pharmacy. The documentation does not support an extreme emergency that would require the drug be immediately supplied and the drug could not have been received from a network pharmacy.We determined that the plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Repatha SureClick 140-milligram per milliliter subcutaneous injection pen prescribed for the treatment of hyperlipidemia with coronary artery disease and type 2 diabetes. 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 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. Repatha SureClick is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale as to why the formulary alternative drug included in the plan, Praluent, would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylprednisolone 32 milligram tablet prescribed for hypomagnesemia. 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 prescriber indicates Methylprednisolone is prescribed to prevent any severe allergic reactions to contrast dye when undergoing a computed tomography scan that is required due to bile duct dilation. The prescriber indicates the enrollee has an allergy to contrast dye but requires it for the test to fully and properly assess the bile duct dilation. However, 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 Methylprednisolone.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tolvaptan 15 milligram tablet prescribed for hyponatremia.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 prescriber indicates Tolvaptan 15 milligram tablet is prescribed for hyponatremia and the enrollee has a baseline serum sodium less than 125 milliequivalents per liter and the drug will not be used in combination with Jynarque. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plans prior authorization requirements were met. A physician reviewed your appeal and determined that the plan is required to cover Tolvaptan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Stelara 90 milligram/milliliter syringe prescribed as directed for hidradenitis suppurativa. 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 Stelara to treat your hidradenitis suppurativa. 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 Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temazepam 30 milligram capsules prescribed for generalized anxiety 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 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 initial prior authorization questionnaire has no when asked if the enrollee tried the non-High Risk Medication alternative drug Doxepin. It was also indicated that the enrollee had no contraindication to Doxipin. The physician indicates Temazepam 30 milligram capsule is prescribed for generalized anxiety disorder. However, the plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plans prior authorization requirements were not met. A physician reviewed your appeal and determined that the plan is not required to cover Temazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets prescribed as directed for small bowel bacterial overgrowth. 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 indicates Xifaxan was prescribed to treat your small bowel intestinal overgrowth. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Diclofenac Sodium 1 percent topical gel. 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 records submitted at the reconsideration level. The documentation indicates that Diclofenac Sodium gel has been prescribed for the treatment of unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic; pain in right shoulder; and pain in left hip. 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 conditions. Therefore, the drug is being prescribed for non-medically accepted indications 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 a request for coverage of Neupro 4-milligram per 24-hour transdermal patches prescribed for the treatment of restless leg syndrome. 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 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.Neupro is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient patient specific clinical rationale, supported by medical records, as to why all formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Humalog Mix 50/50 KwikPen 100-unit per milliliter subcutaneous injection pen prescribed for the treatment of type 2 diabetes mellitus. 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 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.Humalog Mix 50/50 KwikPen is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient patient specific clinical rationale, supported by medical records, as to why all formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Contour Next test strip prescribed for diabetes. The Part D plan denied the requestWe performed an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Supplies for testing and monitoring blood glucose levels are not considered Part D drugs and may be covered under the Medicare Part B durable medical equipment benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Megace 400-milligram per 10-milliliter oral suspension. The Part D plan denied the request for coverage because the drug was being prescribed for a non-medically accepted indication. 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 diagnosis initially provided by the prescriber to the plan was anorexia and weight loss in an enrollee who is human immunodeficiency virus (HIV) positive. 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.At reconsideration, the prescriber has noted that Megace has been prescribed for acquired immunodeficiency syndrome (AIDS)-related wasting. However, while the submitted medical records support that the enrollee is HIV positive, there is no indication in the medical records that the enrollee has a confirmed diagnosis of AIDS. 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 Aimovig 70 milligram/milliliter auto-injector to treat migraine, unspecified, not intractable, without status migrainosus. 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. The prescriber has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug.  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 Corlanor 5 milligram tablet prescribed twice daily for sinus tachycardia. 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 documentation shows the prescriber ordered Corlanor to treat the enrollees sinus tachycardia. However, the Medicare approved compendia do not support the use of this drug for this diagnosis. A physician reviewed the appeal and determined that the plan is not required to cover Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300-milligrams/2-milliliters Subcutaneous Solution Prefilled Syringe to treat pruritus and prurigo nodularis. 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 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. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.