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

At issue is Procrit 40000-units/milliliter Injection Subcutaneous to treat anemia associated with chronic renal failure. The 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 Neupro 4 milligram topical patch 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. Neupro is a brand drug on Tier 4 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 Trulicity Pen Injector 0.75 milligram/0.5 milliliter prescribed to take weekly for type 2 diabetes mellitus with diabetic neuropathy, unspecified.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. Your prescriber does not state 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 Trulicity Pen Injector.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 3% gel prescribed for pain in left knee. 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 Diclofenac Sodium 3% to treat your pain in left knee. 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 Diclofenac Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron HCL 8 milligram tablet prescribed for nausea and vomiting due to achalasia of cardia. 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 and other documentation to show why you need this medication. We did not receive the documentation requested. The documentation shows your doctor prescribed Ondansetron HCL to treat your nausea and vomiting due to achalasia of cardia. 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 Ondansetron HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60-milligrams/milliliter to treat osteoporosis in post-menopausal female. 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 Nuzyra 150 milligram tablet prescribed for a cutaneous abscess. 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 Nuzyra to treat a cutaneous abscess. 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 Nuzyra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Losartan Potassium 50 milligram tablet. 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.Medicare Part D does not cover drugs dispensed from an out-of-network pharmacy. The record shows that you obtained the Losartan Potassium from an out-of-network pharmacy. Therefore, we determined that the plan is not required to reimburse you for the drug. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gabapentin 100 milligram capsules prescribed daily for primary generalized osteoarthritis. 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. The documentation shows your doctor prescribed Gabapentin to treat your primary generalized osteoarthritis. 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 Gabapentin.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Lynparza 150 milligram tablet prescribed two tablets twice daily for malignant neoplasm of prostate. 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. Your medical records show your doctor prescribed Lynparza to treat your malignant neoplasm of prostate. You were on Xtandi and Lupron, but prostate-specific antigen (PSA) was increasing and imaging showed increased bony disease. Molecular profiling done showing CHEK2 mutation. The following citation was referenced in the American Hospital Formulary Service Drug Information, a Medicare approved compendium, and supports the use of this drug for your condition: Lynparza is indicated for 'metastatic castrate resistant prostate cancer, with deleterious germline or somatic homologous recombination repair (HRR) gene mutation, with progression following Xtandi or Zytiga'. A physician reviewed your appeal and determined that the plan is required to cover Lynparza. You meet all criteria as you have castrate resistant disease due to progression on Lupron, have deleterious HRR gene mutation (CHEK2 mutation is part of HRR gene panel), and have progressed on Xtandi.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lotemax 0.5% eye ointment prescribed as needed for allergic blepharitis. 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 Lotemax to treat your allergic blepharitis. 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 Lotemax.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% patch prescribed daily for chronic pain related to lumbar degenerative disc disease and lumbar radiculopathy. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows the doctor prescribed Diclofenac Epolamine 1.3% patch to treat your chronic pain related to lumbar degenerative disc disease and lumbar radiculopathy. 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 Diclofenac Epolamine 1.3% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Colistimethate Sodium 150 milligram nebulizer solution prescribed for an infection in an enrollee with cystic fibrosis post lung transplant. The Part D plan denied coverage.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 on hand includes a physician supporting statement. The supporting statement indicates the drug at issue is for use with a nebulizer in the enrollee's home. The drug is eligible for coverage under Part B.The requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Belbuca 300 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. 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 Megestrol Acetate suspension 400 milligrams/milliliter prescribed for abnormal weight loss and hypomagnesemia. 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.The documentation shows your doctor prescribed Megestrol Acetate to treat your abnormal weight loss and hypomagnesemia. However, the Medicare approved compendia do not support the use of this drug for your conditions. A physician reviewed your appeal and determined that the plan is not required to cover Megestrol Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colesevelam Hydrochloride 625 milligram tablets prescribed six tablets a day for mixed 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. 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. Specifically, you have not tried Cholestyramine or Colestipol.A physician reviewed your appeal and determined that the plan is not required to cover Colesevelam Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cuvitru 2 gram/10-milliliter solution prescribed intravenously weekly for other specified disorders involving the immune mechanism, not elsewhere classified (D89.89). 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 Cuvitru to treat your other specified disorders involving the immune mechanism as subcutaneous immunoglobulin therapy at home. Based on the information provided, we determined the drug would be eligible for coverage under Part B.  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 Percocet Tablets 7.5-325 prescribed for chronic pain due to cervical spondylosis and thoracic and lumbosacral spondylosis. 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. We requested additional information from the prescriber. In this case, your physician has not indicated 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 Percocet Tablets 7.5-325.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested ZTlido Patch 1.8% prescribed for fibromyalgia, chronic pain syndrome and discitis, unspecified, lumbosacral region. 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. Your prescriber indicates you had a recent outbreak of shingles and is not experiencing poster herpatic neuralgia and the ZTlido patches worked in controlling neuralgia. 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 ZTlido Patch 1.8%.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed for muscle spasms due to chronic low back pain. 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 Cyclobenzaprine Hydrochloride for muscle spasms due to chronic low back pain. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As the drug was not 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 Mycophenolate Acid 180 milligram tablet prescribed for post liver transplant. 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 documentation shows your doctor prescribed Mycophenolate Acid to treat your post liver transplant. However, the Medicare approved compendia only support Mycophenolate Acid if also using a calcineurin inhibitor with or without corticosteroids. A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate Acid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 5 milligram capsules prescribed as directed for epilepsy unspecified, not intractable, without status epilepticus. 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 epilepsy unspecified, not intractable, without status epilepticus. 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

You requested Budesonide 0.5 milligram/2 milliliter nebulizer solution prescribed for asthma. The Part D plan denied the 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 drug at issue is for use with a nebulizer in the enrollees home. The drug is eligible for coverage under Part B. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epidiolex solution 100milligram/milliliter prescribed 1.5 milliliter by mouth two times daily for localization-related symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus. 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 also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Epidiolex to treat your epilepsy. 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 Epidiolex. The prior authorization states you must be diagnosed with Lennox-Gastaut syndrome, seizure-tuberous sclerosis syndrome, or severe myoclonic epilepsy in infancy. 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 Lidocaine Hydrochloride Urethral/Mucosal 2% gel prescribed for second degree burn of the left foot. The Part D plan did not make a decision and was auto-forwarded by the plan. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows the doctor prescribed Lidocaine Hydrochloride Urethral/Mucosal 2% gel to treat the enrollees second degree burn of the left foot. However, the Medicare approved compendia do not support the use of this form of the drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine Hydrochloride Urethral/Mucosal 2% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cayston inhalation powder for solution 75 milligrams per vial prescribed for interstitial lung disease, bronchiectasis, and chronic pseudomonas infections. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Cayston inhalation powder for solution to treat enrollees chronic pseudomonas infections. However, the Medicare approved compendia do not support the use of this form of the drug for this condition. A physician reviewed this appeal and determined that the plan is not required to cover Cayston inhalation powder for solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 20 milligram capsules prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Linzess is a brand drug on Tier 4 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.