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

At issue is a request for coverage of Harvoni 90-400 milligram tablets prescribed for treatment-naive chronic hepatitis C infection with decompensated cirrhosis, genotype 3. 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 Medicare approved compendia do not contain any citations to support the use of Harvoni for the treatment of chronic hepatitis C, genotype 3. 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 the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Siliq solution pre-filled syringe 210 milligram/1.5 milliliter prescribed for hidradenitis suppurativa. 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 Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. A physician reviewed your appeal and determined that the plan is not required to cover Siliq.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Supartz FX 25 milligram/2.5 milliliter syringe prescribed for injection into the 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. We determined that the plan is not required to cover the Supartz FX. Supartz FX is a drug that is injected into the knee and is considered a device by the Food and Drug Administration. Therefore, the device is excluded from coverage under Medicare Part D. The Supartz FX may be covered under Medicare Part B. Please submit your request to Part B. The decision does not address medical necessity of the device. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Spravato 84 milligram spray prescribed for major depressive disorder with psychotic features. 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 record shows Spravato is being supplied by you and administered to the enrollee, in your office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover Spravato. Please submit your request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested compounded drug Naltrexone HCL 50 milligram tablet/Lactose Monohydrate powder/Lactose Monohydrate spray dried powder/capsule prescribed for unknown diagnosis. The 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.According to Medicare rules, drugs that fall into the category of bulk powders are excluded from coverage under Part D. In addition, Medicare Part D does not cover non-prescription drugs. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drugs are non-prescription or over-the-counter (OTC) drugs. Therefore, the Lactose portion of the compound is not eligible for Part D coverage. Therefore, we determined that the plan is not required to cover the Naltrexone HCL 50 milligram tablet/Lactose Monohydrate powder/Lactose Monohydrate spray dried powder/capsule. 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 Armour Thyroid 90 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 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 Shingrix 50 microgram per 0.5 milliliter vaccine. 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 you have already received the Shingrix vaccine twice. The plans quantity limit is two doses per lifetime. There were no medical records submitted for review to support why an exception to the plans quantity limit is medically necessary. A physician reviewed your appeal and determined that the plan is not required to reimburse the Shingrix vaccine, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Ofev 100 milligram capsules prescribed for chronic fibrosing interstitial lung disease. 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 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 of this medication will be approved. 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

At issue is Shingrix intramuscular suspension kit. 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.Shingrix is a biological product drug on Tier 4 of the plans formulary. There are no biological product 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 Hyoscyamine Sulfate 0.125 milligram sublingual tablet. The Part D Plan denied your request because Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. 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 record shows Hyoscyamine Sulfate is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. 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.A physician reviewed your appeal and determined that the plan is not required to cover Hyoscyamine Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amitriptyline Hydrochloride 25 milligram tablet prescribed for chronic pruritus. 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 documentation shows your doctor prescribed Amitriptyline Hydrochloride 25 milligram tablets to treat your chronic pruritus. 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 Amitriptyline Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acyclovir 5% ointment prescribed daily for recurrent herpetic genital ulceration. 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.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. A physician reviewed the appeal and determined that the plan is not required to cover Acyclovir 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Darzalex 400 milligram/20-milliliter solution prescribed as directed for multiple myeloma/plasmacytoma. The Part D plan denied your request. The Part D plan denied the request. The requested drug is not on the plans formulary. 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.This medication is not on your plan's list of medications. The prescriber has not given a clear medical reason why all medications required by the plan on that list did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. 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 Lidocaine 5% ointment prescribed for 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 did not include medical records or a supporting statement from the prescriber. The documentation indicates the prescriber originally ordered the drug at issue for knee osteoarthritis. A request for medical records and a supporting statement was sent to the prescriber; a supporting statement was submitted. The statement indicates the diagnosis should be for low back pain; however, there are no medical records submitted to support a covered diagnosis. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed. Of note, you requested a quantity greater than the plans allowance. As the drug cannot be covered, a quantity limit exception cannot be granted.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 Pregabalin 75 milligram capsules prescribed for neuropathy. 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 Pregabalin for neuropathy. 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

At issue is Femara 25 milligram tablet. 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

At issue is Diclofenac Epolamine 1.3% patch prescribed for pain due to trauma. 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 requested additional information from your prescriber. Your prescriber indicates they prescribed Diclofenac Epolamine 1.3% patch to treat acute pain due to minor sprains, strains, and contusions. However, there were no medical records submitted to support the diagnosis. In addition, 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  Diclofenac Epolamine 1.3% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Deferiprone 500 milligram tablet prescribed one tablet three times daily for transfusional iron overload related to myelodysplastic 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. Your medical records show your doctor prescribed Deferiprone to treat your transfusional iron overload related to myelodysplastic syndrome. However, the Medicare approved compendia do not support the use of this drug for your condition. A negative citation in Micromedex, a Medicare approved compendium states;  Safety and effectiveness have not been established for the treatment of transfusional iron overload in patients with myelodysplastic syndrome. A physician reviewed your appeal and determined that the plan is not required to cover Deferiprone. Safety and effectiveness have not been established for the treatment of iron overload in a patient with myelodysplastic syndrome.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablets prescribed for chronic heart failure. 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 medical records show your doctor prescribed Corlanor to treat your chronic heart failure. 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 Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sulfacetamide Sodium-Sulfur 10-5% emulsion prescribed three time daily for acne. 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. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.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. A physician reviewed the appeal and determined that the plan is not required to cover Sulfacetamide Sodium-Sulfur 10-5% emulsion.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 2.5 milligram capsule prescribed daily for loss of appetite due to end stage chronic obstructive pulmonary disease. 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 Dronabinol to treat the enrollees loss of appetite due to end stage chronic obstructive pulmonary disease. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Xeljanz XR 11 milligram extended release 24-hour tablets. 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 medical records indicate that Xeljanz XR has been prescribed for the treatment of ankylosing spondylitis. 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 the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor, 5 milligram tablet, prescribed one tablet twice a day for atherosclerotic heart disease and chronic heart failure. The Part D plan denied the request because it does not meet the plans criteria. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia.At reconsideration, Corlanor 5 milligram tablet is prescribed one tablet twice a day for atherosclerotic heart disease and chronic heart failure. Micromedex, a Medicare approved compendium, states:  Ivabradine is indicated in adult patients with stable, symptomatic chronic heart failure to reduce the risk of hospitalization for worsening heart failure. It should only be used in patients with an ejection fraction of 35% or less who are in sinus rhythm, have a resting heart rate of at least 70 beats per minute, and are receiving the maximally tolerated beta-blocker dose (or have a contraindication to beta-blocker use). Therefore, this drug is being requested for a non-medically accepted indication based on the information provided; patient is not in a sinus rhythym.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 Wixela Diskus Inhalation Blisters. 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 included on Tier 1 of the plans formulary. There are no cost-sharing tiers lower than Tier 1; therefore, a tier exception cannot be considered.  A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.