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

You requested Lyrica 150 milligram capsules prescribed three times daily for polyneuropathy unspecified, other chronic pain, and low back pain. 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. Your medical records show your doctor prescribed Lyrica to treat your polyneuropathy unspecified, other chronic pain, and low back pain. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and determined that the plan is not required to cover Lyrica.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sprix Solution 15.75 milligram/spray prescribed for migraines. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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. Your physician submitted a supporting statement. 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.A physician reviewed your appeal and determined that the plan is not required to cover Sprix.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Orphenadrine ER 100 milligram tablets prescribed twice daily as needed for multiple sclerosis and chronic pain 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Orphenadrine to treat your multiple sclerosis and chronic pain syndrome. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and determined that the plan is not required to cover the Orphenadrine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Lantus 100 units/milliliter vial prescribed for type 2 diabetes mellitus. The Part D plan denied your request for a tiering exception because Lantus is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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. The plan shows Lantus is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium Gel 1% Topical to treat cervicalgia. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Praluent 75 milligrams/milliliter injection pen  prescribed as directed for primary 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 information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Praluent.A physician reviewed your appeal and determined that the plan is not required to cover the Praluent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexium 40 milligram delayed release oral capsule for gastroesophageal reflux. 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 auto-forwarded reconsideration request from the coverage level.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. 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 prescriber submitted a supporting statement that shows Nexium was prescribed to treat your gastroesophageal reflux. The Medicare approved compendia do support the use of this drug for your condition. The plan requires an intolerance or contraindication to the generic equivalent agent Pantoprazole Sodium or Omeprazole before they will cover the requested drug. The prescriber did not provide any clinical evidence to support you have tried and failed or have an intolerance to the generic equivalent agent. 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 Nexium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol 180 milligram tablet prescribed for high cholesterol (particularly low-density lipoprotein). The Part D plan denied your request. 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 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 records submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Nexletol for your condition. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol 0.05 milligram patch to treat the enrollees condition. The Part D plan did not provide a timely redetermination decision.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 a physicians statement indicating the need for the requested drug, and to provide a diagnosis and supporting medical records. A reply from the prescriber was not received.Estradiol 0.05 milligram patch is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain 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 coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Estradiol 0.05 milligram patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sensipar 60 milligram tablets prescribed daily for hyperthyroidism of renal origin. The Part D plan was unable to review your case timely and auto-forwarded 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. According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. We determined that the plan is not required to cover the Sensipar. Drugs which are eligible for Part B coverage are excluded from Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus one milligram capsule prescribed for post kidney transplant. 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 your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The record shows you were enrolled in Medicare when you had your transplant on October 5, 2011. Therefore, this drug may be eligible for coverage under Medicare Part B. 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 Desvenlafaxine Succinate ER 100 milligram tablet to treat recurrent major depression 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 information submitted at the reconsideration level. We asked the prescriber to send us a prescriber statement and medical records to show why the enrollee needs this medication. We did not receive the documentation requested.The plan requires an intolerance or contraindication to two of the following: Serotonin and Norepinephrine Reuptake Inhibitors, Selective Serotonin Reuptake Inhibitors, Mirtazapine, or Bupropion 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 Desvenlafaxine Succinate ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trospium Chloride 60 milligram 24 hour extended-release oral capsule prescribed for overactive bladder. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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. 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 Trospium Chloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cimzia starter kit prescribed for rheumatoid arthritis. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 information submitted at the reconsideration level. The prescriber submitted a supporting statement and medical records that show the enrollee tried and failed many medications including Prednisone, Methotrexate, Plaquenil, Humira, and Simponl. However, 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 Cimzia starter kit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lyrica 150 milligram capsules prescribed three times daily for left trigeminal neuropathy/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. We also researched Medicare systems and reviewed the enrollment data available. 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 Lyrica.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Repatha Sureclick 140 milligrams/milliliter injection pen  prescribed as directed for coronary artery disease involving native coronary artery of native heart 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 information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Repatha Sureclick.A physician reviewed your appeal and  determined that the plan is not required to cover the Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Metoprolol Succinate 25 milligram tablets prescribed for hypertension. The Part D plan denied the request for coverage stating that a recurring supply over 90 days will not be allowed.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.While the plan has stated that the prescriber has requested more than a 90-day supply of Metoprolol Succinate, the submitted documentation does not support this statement. The submitted prescription states for the enrollee to take 1 tablet in the AM and 12 tablet in the PM. The prescriber has then written 135 tablets for a three-month (90-day) supply. The plans quantity limit for Metoprolol Succinate is 60 tablets per 30 days, or 180 tablets for 90 days. Therefore, 135 tablets for a 90-day supply, which is what has been ordered by the prescriber, does not exceed the plans quantity limits for Metoprolol Succinate. A physician reviewed the appeal and determined that the plan is required to cover 135 tablets of Metoprolol Succinate per 90-day supply.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira 40-milligrams/0.4-milliliter Pen subcutaneous to treat ankylosing spondylitis of multiple sites in spine. 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and 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 Cosentyx 150 milligram/milliliter pen injector prescribed for plaque psoriasis. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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. Your physician submitted a supporting statement. 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.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 Hyoscyamine Sulfate 0.125-milligram tablet to treat irritable bowel syndrome with diarrhea. 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 plan denied the request for coverage of the requested drug to treat the provided diagnosis because the plans Medicare Part D drug plan cannot cover drugs classified as being part of the Food and Drug Administration (FDA)'s Drug Efficacy Study Implementation (DESI) program. These drugs are considered to be Less than Effective (LTE) per FDA review.A physician reviewed the appeal and determined that the requested drug is excluded from Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cinacalcet HCL 30 mg tablets to treat secondary hyperparathyroidism in an enrollee with chronic kidney disease who is not on dialysis, and hypercalcemia. 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 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 Cinacalcet HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Cypionate 200 milligram solution prescribed for primary hypogonadism. The Part D plan denied your request. 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 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 records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of primary hypogonadism. However, the enrollee does not 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

At issue is Northera 300 milligram capsules. 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and medical records have not been provided. A physician reviewed your appeal and determined that the plan is not required to cover Northera.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benzonatate 100 milligram capsule to treat your cough. 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.We determined that the plan is not required to cover Benzonatate because it was for the symptomatic relief of coughs. Drugs prescribed for symptomatic relief of cough are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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.