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

At issue is Xeljanz 11 milligram extended-release oral tablet for ulcerative 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. Your medical records show your doctor prescribed Xeljanz to treat your ulcerative colitis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Medical records indicate the enrollee has tried and failed Mesalamine, Remicade, and Entyvio. Additionally, medical records indicate coverage of Stelara was denied. There is no indication that medications other than Xeljanz are planned or in current use for immunosuppression. This history is also verified on a prescriber statement. Negative testing for viruses and tuberculosis is also included in the test results in the medical records provided. Xeljanz 11 milligram extended-release daily is appropriate to use after 8 weeks of induction w/ Xeljanz 22 milligram extended-release daily.A physician reviewed your appeal and determined that the plan is required to cover Xeljanz 22 milligram extended-release within the parameters of the plan's quantity limits, if applicable. The physician reviewer also determined that the plans prior authorization requirements have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Xeljanz 22 milligram extended-release oral tablet for ulcerative 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. Your medical records show your doctor prescribed Xeljanz to treat your ulcerative colitis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Medical records indicate the enrollee has tried and failed Mesalamine, Remicade, and Entyvio. Additionally, medical records indicate coverage of Stelara was denied. There is no indication that medications other than Xeljanz are planned or in current use for immunosuppression. This history is also verified on prescriber statement. Testing for viruses and tuberculosis is also included in the test results in the medical records provided.  Eight weeks of induction w/ Xeljanz 22 milligram extended-release daily is the appropriate dosing for this medically accepted indication.A physician reviewed your appeal and determined that the plan is required to cover Xeljanz 22 milligram extended-release within the parameters of the plan's quantity limits, if applicable. The physician reviewer also determined that the plans prior authorization requirements have been met.
Appeal type: Prescription Drug
Decision: Favorable

You requested Prolia 60 milligram/milliliter syringe prescriber for osteoporosis in a post-menopausal woman at high risk for fractures. The Part D plan denied the request and indicated it was approved under Part B. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The prescriber has indicate that the original questionnaire included some wrong information and that the pharmacy would be dispensing the medication to the enrollee to take home and inject at her home and this should be approved under Part D. The provider also confirmed they were asking for 1 Prolia 60 milligram syringe per 180 days and not per 90 days. The clarification of the quantity is within the quantity limits of the plan and the drug is covered under Part D as the enrollee will be getting it from the pharmacy and injecting it at home.  A physician reviewed your appeal and determined that the plan is required to cover Prolia 60 milligram/milliliter 1 syringe per 180 days.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 microgram metered dose inhaler prescribed for chronic obstructive pulmonary disease. 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. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective. Medical records to support the use of formulary medications were not submitted. A physician reviewed your appeal and determined that the plan is not required to cover Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 1% gel prescribed for peripheral vascular disease and unspecified pain in leg. The Part D plan denied your request initially.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.Drugs prescribed that are available over the counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.We determined that the plan is not required to cover Diclofenac Sodium 1%.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Qinlock 50 milligram tablets prescribe to treat gastric gastrointestinal stromal tumor. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The documentation submitted supports two kinase inhibitors, which included Imatinib, were tried. However, there was no indication 3 or more kinase inhibitors had been tried as indicated in the Medicare approved compendia to support the drug is medically accepted and indicated for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Qinlock.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Auryxia 210 milligram tablets prescribed for hyperphosphatemia in an enrollee with chronic kidney disease. 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 indicates your doctor prescribed Auryxia for your hyperphosphatemia. However, the documentation does not support you are on dialysis. The Medicare approved compendia do not support the use of this drug for your condition. 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 Pazopanib prescribe to treat aggressive differentiated follicular cancer, metastatic. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. 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. We did receive a prescriber statement regarding your condition.The Medicare approved compendia, NCCN, supports a 2A recommendation for this diagnosis, it is a medically accepted indication.   However, the documentation does not satisfy the plans prior authorization coverage criteria, approved by Medicare. An exception to the plans coverage criteria cannot be granted. 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 Humira Pen Injector 40 milligram/0.4 milliliters prescribed for sarcoidosis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia does 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 Humira Pen Injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Forteo 600 microgram per 2.4 milliliter subcutaneous injection pen prescribed for an unknown condition. 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 Part D plan has prior authorization requirements that must be met before coverage for Forteo is approved. A request was submitted to the prescriber to provide a diagnosis, to address the plans coverage 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 Forteo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sivextro 200 milligram tablet prescribed for pulmonary mycobacterial infection. 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 indicates your doctor prescribed Sivextro for pulmonary mycobacterial infection. The Medicare approved compendia do not support the use of this drug for your condition. 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

At issue is Latuda 80 milligram tablets prescribed for the enrollees condition. 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.Latuda is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier 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

You requested Tacrolimus 0.1% topical ointment prescribed for mycosis fungoides. 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 indicates your doctor originally prescribed Tacrolimus ointment for mycosis fungoides. Your doctor submitted a supporting statement to indicate the diagnosis should be changed to include atopic dermatitis. However, the medical records submitted do not support the drug at issue was prescribed for atopic dermatitis. 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

At issue is a tiering exception for Torsemide 20 milligram tablet prescribed daily for heart failure with preserved ejection fraction. 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. Torsemide is a generic drug on Tier 2 of the plans formulary. The prescriber has not provided patient specific clinical rationale, with supporting medical documentation, to indicate that all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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 Xeljanz 5 milligram tablets prescribed for alopecia areata universalis. 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 indicates your doctor prescribed Xeljanz for alopecia areata universalis and trachyonychia. The Medicare approved compendia do not support the use of this drug for your condition. 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

At issue is Ondansetron Hydrochloride 4 milligram tablet twice daily to treat nausea and vomiting due to gastritis and gastroparesis. The Part D plan did not make a decision.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 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Scopolamine Patch 1 milligram prescribed for nausea and vomiting in an enrollee not currently receiving any systemic therapy. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia does 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 Scopolamine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Lidocaine 5% patches. 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. You stated that the Lidocaine patches were prescribed for your lower back pain. However, lower back pain is not a specific enough diagnosis to determine if the medication is being prescribed for a medically accepted indication.  A request was submitted to the doctor who prescribed the medication to provide a diagnosis, for clarification, and to provide supporting medical records. A reply from the prescriber was not received. Without a specific 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 Lidocaine 5% patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300-milligrams/2-millilters to treat cicatricial pemphigoid and mucous membrane pemphigoid. 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 Pentasa 500 milligram capsules prescribed two capsules three times daily for Crohns disease. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.This drug is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. 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

You requested Cevimeline Hydrochloride 30 milligram oral capsules prescribed daily for dry mouth, 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. 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 medical records show your doctor prescribed Cevimeline Hydrochloride to treat your dry mouth, unspecified. However, the Medicare approved compendia do not support the use of this drug for your condition. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Cevimeline.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Bupropion XL 150 milligram tablet prescribed for unknown diagnosis. 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. You are requesting reimbursement for Buproprion given to you while in the hospital. We researched Medicare resources and found that the repackaged drug Buproprion has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover the Bupropion. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acetazolamide 250 milligram tablets prescribed to control blood pressure. 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. Acetazolamide is a generic drug on Tier 3 of the plans formulary. Your doctor states that you tried many drugs and have many allergies. However, your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you or if you tried them. 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 Lidocaine 5 percent patch prescribed for autoimmune urticaria. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 record shows you were prescribed the Lidocaine patch for your autoimmune urticaria. The Medicare approved compendia do not support the use of this drug, as prescribed, for your condition. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.