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

At issue is Prolia Solution prescribed every 6 months for osteoporosis. 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. Prolia is a biologic drug on Tier 4 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 Lynparza 150 milligram tablet prescribed two tablets twice daily for ovarian cancer. 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 doctors statement and medical records show Lynparza was prescribed to treat ovarian cancer. 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 Lynparza. 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

You requested Pregabalin 75 milligram capsules prescribed twice daily for chronic female pelvic 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. The documentation shows your doctor prescribed Pregabalin to treat your chronic female pelvic pain. 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 Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Armodafinil 250 milligram tablets. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. 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 Armodafinil has been prescribed for the treatment of idiopathic hypersomnia without long sleep time. 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 your appeal and determined that the plan is not required to cover Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuplazid 34-milligram capsule. At initial determination and redetermination the diagnoses of dystonia, unspecified and hallucinations, unspecified were given. The Part D plan denied the request stating that the provided diagnoses are non-medically accepted indications.  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.At reconsideration diagnoses of major depressive disorder, recurrent, severe, with psychotic symptoms and dystonia were documented in the medical record. The use of the requested drug to treat the provided diagnoses are off-label uses. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. 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

At issue is Mesalamine 800 milligram delayed release tablets prescribed three times daily. 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 is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why 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 Rocklatan 0.02%-0.005% eye drops prescribed to instill 1 drop in right eye at bedtime to treat primary open-angle glaucoma. 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.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 medical records submitted show that 2 of the plans alternative formulary drugs were tried and failed.Rocklatan is a brand 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

You requested Jakafi 5 milligram tablets prescribed as directed for essential thrombocythemia. 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 information regarding the enrollees condition. We also asked for medical records to show why the enrollee needs this medication. We received the documentation and included it in our review.The documentation shows the doctor prescribed Jakafi to treat essential thrombocythemia. The Medicare approved compendia support the use of Jakafi for patients with essential thrombocythemia who have inadequate response, or loss of response, to Hydrea or Anagrelide. The medical records submitted for review support that the enrollee is intolerant to treatment with Anagrelide. However, there is no documentation in the medical records detailing the enrollees inadequate response, or loss of response, to treatment with Hydrea. As such, the documentation does not support that the requested drug has been prescribed in accordance with the Medicare approved compendia. There was insufficient documentation to support that the requested drug was prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover Jakafi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Patch 5 % prescribed to treat 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We requested additional information from your prescriber. The documents submitted support that Lidocaine Patch 5% is being prescribed for chronic pain syndrome. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The diagnosis submitted does not meet the prior authorization requirements. The enrollee has not satisfied the plan's coverage criteria. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine Patch. 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 Glucotrol 5 milligram oral tablet prescribed daily. 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. We asked your prescriber to send us information about 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 similar medications on the lower tiers would not work for you. We received the documentation and included it in our review.Glucotrol is a brand 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 Lidocaine 5% Patch to treat low back pain, acute, due to fall. 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 Lidocaine 5% patch prescribed for 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. The documentation shows Lidocaine 5% patch was prescribed to treat chronic low back pain related to paraproteinemia. 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 Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Doxycycline Monohydrate 75 milligram capsules. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. During this review, a prescriber statement and supporting medical records were requested from your doctor to address the tiering exception request. The doctor did not respond to our request.Doxycycline Monohydrate is a generic drug on Tier 4 of the plans formulary. The prescribing physician has not addressed why the generic drugs of the same type on the lower tiers of the plans formulary to treat your condition have been tried and failed, or are contraindicated. A physician reviewed the appeal and determined that the plan is not required to cover the Doxycycline Monohydrate at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Retin-A Micro 0.1% gel prescribed for acne and rosacea. 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. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.The doctor prescribed Retin-A for the enrollees acne. No medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.The prescriber requested Retin-A 0.025% cream; however, the plan does not have an appeal on file for this drug. The prescriber will need to submit an appeal to the plan before we can review this drug.A physician reviewed your appeal and determined that the plan is not required to cover Retin-A Micro 0.1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram capsules prescribed for nausea with vomiting, unspecified, gastroparesis, and type 2 diabetes mellitus without complications. 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 nausea with vomiting, unspecified, gastroparesis, and type 2 diabetes mellitus without complications. 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 Metaxalone 800 milligram tablets prescribed for chronic muscle spasms. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The records show your physician prescribed Metaxalone 800 milligram tablets to treat your chronic muscle spasms. 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 Metaxalone 800 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Auryxia 210 milligram oral 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. The medical records show your doctor prescribed Auryxia to treat your iron deficiency with low grade hyperphosphatemia in chronic kidney disease, not on dialysis. 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 Auryxia.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Prolia 60-milligram Solution Prefilled Syringe to treat osteopenia with malignant neoplasm of left breast. 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 satisfies the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets prescribed twice daily. 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. Eliquis 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 Belbuca Film 75 micrograms. 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.We requested additional information from your prescriber but did not receive a response. The information is insufficient to determine if the medication is medically indicated for your condition.  A physician reviewed your appeal and determined that the plan is not required to cover Belbuca Film.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fentanyl Transdermal Patch 50 microgram prescribed to treat chronic 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your prescriber submitted medical records that do not support the medication is being given in combination with Medication Assisted Treatment therapy or that a pain management agreement has been signed by the patient and prescriber in the past 6 months.  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 not met. A physician reviewed your appeal and determined that the plan is not required to cover Fentanyl Transdermal Patch. 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 Xiidra 5% eye drops. 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.Xiidra 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

You requested Ibrance 100 milligram tablet prescribed for hormone receptor-positive, human epidermal growth factor receptor 2-negative male breast cancer in combination with Letrozole. 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 did not receive the documentation requested. The records show you prescribed Ibrance 100 milligram tablet to treat the enrollees hormone receptor-positive human epidermal growth factor receptor 2-negative male breast cancer in combination with Letrozole. The medical record submitted do not adequately support the enrollee has advanced, unresectable or metastatic disease. Therefore, 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 Ibrance 100 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. At initial determination the diagnosis of Fibromyalgia was given. At redetermination the diagnosis of chronic pain syndrome due to low back pain was given. The medical records show your doctor prescribed Lidocaine to treat your chronic low back pain. 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 Lidocaine patch.