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

At issue is Belbuca 75 milligram buccal film prescribed for 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. Belbuca 75 milligram buccal film was prescribed to treat your chronic pain syndrome. 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 you. A physician reviewed your appeal and determined that the plan is not required to cover Belbuca.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acthar 80 units/milliliter vial to treat polymyositis and rheumatoid arthritis. 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 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 Zofran 8 milligram tablets. 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 not included on your plans formulary. Per Medicare rules, non-formulary drugs are 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 Novolog 100 Units/milliliter vial 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. Novolog is a biologic drug on Tier 3 of the plans formulary. There are no biologic drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is OmniPod Dash 5 pack insulin pod subcutaneous cartridge 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. OmniPod Dash is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nitrofurantoin 25 milligrams/milliliter oral suspension prescribed as directed for a urinary tract infection. 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. 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 all other drugs on the plans formulary would not work for you.A physician reviewed your appeal and determined that the plan is not required to cover Nitrofurantoin oral suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% Patch to treat lower back pain and chronic pain. 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 prior authorization criteria, and to provide supporting medical records. A reply from the prescriber was not received. 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 Doxepin Hydrochloride 10 milligram capsules prescribed twice daily for dermatitis, unspecified. 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 Doxepin Hydrochloride to treat your dermatitis, unspecified. 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 Doxepin Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Trokendi 50 milligram XR capsules. 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 does not include medical records or a supporting statement. A request for information was sent to the prescriber; however, no further documentation was received. 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

You requested Prolia 60 milligram/milliliter prescribed as directed for the enrollees condition. 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 and why it is being prescribed. We did not receive the documentation requested.Your medical records show your doctor prescribed Prolia but your condition is not specified. Therefore, we cannot determine if the Medicare approved compendia supports the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Prolia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Amitiza 8-microgram tablet to treat irritable bowel syndrome with constipation. 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.Amitiza 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 a request for coverage of Prednisone 50 milligram tablets prescribed for an unknown condition. The Part D plan denied the request because the prior authorization requirements were not met.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. The documentation does not include any medical records from the prescriber. A request was submitted to the prescriber to address the coverage requirements and to provide a diagnosis and supporting medical records. A reply from the prescriber was not received. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage under Part D, the plans prior authorization requirements are not applicable to this review.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide EC 3 milligram capsules prescribed for colitis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Budesonide EC 3 milligram capsules to treat your colitis. Medical records were provided which substantiate the diagnosis of colitis. 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 Budesonide EC capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Corlanor 5 milligram tablets prescribed for postural orthostatic tachycardia syndrome, mild cardiomyopathy, and unspecified cardiac arrhythmias. 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 Corlanor 5 milligram tablets for postural orthostatic tachycardia syndrome, mild cardiomyopathy, and unspecified cardiac arrhythmias. 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 Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligrams/2 milliliters injection prescribed for an unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. 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.A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  Without a diagnosis, 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

You requested Shingrix 50 microgram/0.5 milliliter suspension prescribed for vaccination. 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 plan submitted documentation that shows you were still in the deductible stage of the Part D benefit when you purchased the vaccine at your preferred pharmacy. Your plans Evidence of Coverage states that you are responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined the amount you paid was applied to your deductible and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for OxyContin ER 30 milligram 12-hour abuse-deterrent tablets prescribed for an unknown condition for the dates of service of January 13, 2021; February 12, 2021; March 14, 2021; and April 13, 2021. 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.OxyContin ER tablets are not included in your plans formulary (list of covered drugs). A request was submitted to your doctor to provide a diagnosis, to address the alternative medications that are included in the plans formulary to treat your condition, and to provide supporting medical records. A reply from your doctor was not received. Without a diagnosis 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 reimburse the amount paid for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Abiraterone Acetate 250 milligram tablet. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.The records show you prescribed Abiraterone Acetate 250 milligram tablet to treat the enrollees condition. However, there are no medical records provided to support a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Abiraterone Acetate 250 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is NP Thyroid 60 milligram tablet prescribed for 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.Non-FDA approved drugs are excluded from Medicare Part D coverage. Therefore, NP Thyroid is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clindamycin 1% Solution 720 milliliters per 28 days prescribed for a rash/skin eruption that is caused by the drug, Erlotinib, which the enrollee receives for cancer treatment and will require for 4 years. The Part D plan denied your request for a quantity 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. The documentation shows your doctor prescribed Clindamycin 1% Solution 720 milliliters per 28 days for a rash/skin eruption that is caused by the drug, Erlotinib, which the enrollee receives on a regular basis for cancer treatment. 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 Clindamycin 1% Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Enoxaparin 80 milligram/0.8 milliliter syringe. 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. Enoxaparin is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why all of the drugs available on the lower tiers of your plans formulary would not work for you. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Rivastigmine 4.6 milligram per 24 hour patches prescribed for an unknown condition. 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. Rivastigmine is not included in the plans formulary. The documentation does not include any medical records from the prescriber. A request was submitted to the prescriber to provide a diagnosis and supporting medical records and to address the alternative medications included in the plans formulary to treat the enrollees condition. A reply from the prescriber was not received. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested 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 Nourianz 20-milligram tablet 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium gel 3% prescribed for osteoarthritis of the hands and wrists. 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. We received the documentation and included it in our review. Your medical records show your doctor prescribed Diclofenac Sodium gel 3% to treat osteoarthritis of the hands and wrists. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Diclofenac sodium topical 1% gel is indicated for the relief of pain due to osteoarthritis of joints amenable to topical treatment, such as the hands and knees. A physician reviewed your appeal and determined that the plan is not required Diclofenac Sodium gel 3%.
Appeal type: Prescription Drug
Decision: Favorable

You requested Lidocaine 5% patch prescribed for diabetic polyneuropathy. 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 documentation indicates your doctor originally prescribed Lidocaine patches for chronic back pain. Your prescriber submitted progress notes to support the Lidocaine patches at issue were prescribed for diabetic polyneuropathy. The Medicare approved compendia contain a citation to support the use of the drug for your 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 Vraylar 1.5 milligram capsule prescribed for bipolar disorder. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need this medication. We did not receive the documentation requested. The documentation shows your doctor prescribed Vraylar to treat your bipolar disorder. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided 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 Vraylar. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.