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

You requested Diclofenac Epolamine 1.3% patch prescribed for lumbosacral radiculopathy. 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 you prescribed Diclofenac Epolamine 1.3% patch to treat the enrollees lumbosacral 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 Nexium DR 40 milligram capsule prescribed twice daily for Barretts esophagus. 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. Nexium DR 40 milligram capsule 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 Zolpidem Tartrate 10 milligram tablet prescribed daily for insomnia due to severe pain. 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 also researched Medicare systems and reviewed the enrollment data available.Zolpidem Tartrate was prescribed to treat insomnia. The 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 Zolpidem Tartrate. 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: Favorable

At issue is Kisqali 600 milligram tablet therapy pack prescribed for metastatic breast cancer, estrogen/progesterone receptor positive, human epidermal growth factor receptor 2 negative. 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. The medical records show you prescribed Kisqali 600 milligram tablet therapy pack in combination with Exemestane as first line treatment for the enrollees metastatic breast cancer, estrogen/progesterone receptor positive, human epidermal growth factor receptor 2 negative. The 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. However, the oncologist reviewer has determined that an exception to the plans prior authorization requirements can be granted at this time as this medication is Food and Drug Administration approved for the diagnosis and is a Category 1 recommendation of the National Comprehensive Cancer Network. A physician reviewed your appeal and determined that the plan is required to cover Kisqali 600 milligram tablet therapy pack.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Shingrix Vial Kit 50 micrograms per 0.5-milliliter intramuscular suspension reconstituted for shingles prophylaxis. The Part D plan denied your 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.Shingrix Vial Kit is a biologic on Tier 4 of the plans formulary. There are no drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Qnasl 80 microgram aerosol solution prescribed for asthma. 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 your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you.  However, we did not receive the documentation.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 Qnasl.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets prescribed for small intestinal bacterial overgrowth with extreme abdominal 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. Your medical records show your doctor prescribed Xifaxan to treat your small intestinal bacterial overgrowth with extreme abdominal pain. 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 Xifaxan. The Medicare approved compendia do not support the use of this drug for your condition. 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 a request for coverage of Neupro 4 milligram per 24 hour transdermal patches prescribed for Parkinsons 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 your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The plan has a step therapy requirement for Neupro transdermal patches. Before this drug is covered, the enrollee must try two of the following: Ropinirole, Ropinirole ER, or Pramipexole. At reconsideration, the prescriber has noted that the enrollee became violently ill on Requip (Ropinirole). However, no medical records have been submitted to validate this statement. Furthermore, the submitted documentation does not show that the enrollee has failed to achieve symptom control after prior therapy with or cannot use Pramipexole. Therefore, the plans prior step therapy requirements have not been satisfied. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Oxycodone Hydrochloride 30 milligram tablet prescribed every 3 to 4 hours as needed for severe pain due to post laminectomy syndrome. The case 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.Oxycodone Hydrochloride 30 mg tablets was prescribed 8 tablets per day to treat the enrollees condition. This enrollee has severe, chronic, around the clock pain and is documented to have been using up to 585 MME (morphine milligram equivalents) to control symptoms. This enrollee is being managed in a pain management practice, with a goal of reducing the number of different types and quantity of opiates. There is a detailed plan provided in the medical record, most recent visit April 21, 2021, of how provider is planning to titrate down total opiate dosage. There is an opiate agreement in place. The total daily dosage of the requested drug does not exceed the maximum dosage in the Medicare compendia. The prescriber has indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition. Therefore, an exception to the plans coverage criteria is supported.A physician reviewed your appeal and determined that the plan is required to cover the Oxycodone Hydrochloride as prescribed.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclosporine 25 milligram capsules prescribed daily for end stage renal disease. 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.  According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. We determined that the plan is not required to cover the Cyclosporine. Drugs which are eligible for Part B coverage are excluded from Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Progesterone 200 milligram capsules prescribed daily for chronic intractable migraine headaches with history of hemiplegia with headache, and mast cell activation syndrome. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Progesterone to treat your chronic intractable migraine headaches with history of hemiplegia with headache, and mast cell activation syndrome. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and determined that the plan is not required to cover the Progesterone.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mycophenolate Mofetil 500 milligram tablets  to for treatment after a kidney transplant. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited 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. We also researched Medicare systems and reviewed the enrollment data available.The medication requested is for a medically accepted indication. It is a formulary medication. It is subject to prior authorization, to determine whether coverage is provided under the Part D drug program. Transplants that were not paid for by Medicare receive this medication under Part D. Based on the best information available, including the Health Insurance Master Record, the transplant was not paid for by Medicare.A physician reviewed the appeal and determined that the requested drug is covered under Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trelegy Ellipta 100-62.5 microgram inhalation powder prescribed for 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 your case file carefully. We reviewed all documentation submitted. Trelegy Ellipta is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Trelegy Ellipta at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Saxenda 18 milligrams/3 milliliters injection pen prescribed for metabolic syndrome. 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. We determined that the plan is not required to cover Saxenda because drugs used for weight loss are excluded from coverage. 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 Cresemba 186 milligram capsule prescribed twice daily for antifungal prophylaxis following stem cell transplant. 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 Cresemba for antifungal prophylaxis following stem cell transplant. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron Hydrochloride 4 milligram tablets prescribed for nausea associated with migraine headaches. 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. The submitted documentation indicates your doctor prescribed Ondansetron Hydrochloride for nausea associated with migraine headaches. 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 Budesonide-Formoterol 160-4.5 micrograms/actuation for inhalation prescribed as directed for wheezing and cough. 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 the doctor prescribed Budesonide-Formoterol to treat wheezing and cough. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Budesonide-Formoterol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide/Formoterol 160-4.5 prescribed for wheezing and cough. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Budesonide/Formoterol to treat your wheezing and cough. 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 Budesonide/Formoterol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Olopatadine Hydrochloride 0.1% Eye Drops prescribed once a day for excessive watering, itching, and irritation of eyes from allergies. 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 indicates you have tried Olopatadine 0.2% and it was not effective and the patient is stable on the current drug. There was no documentation that you had previous treatment or intolerance to two of the following: Olopatadine 0.2%, Azelastine, and Cromolyn Eye Drops.Your medical records show your doctor prescribed Olopatadine Hydrochloride 0.1% Eye Drops. 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 Olopatadine Hydrochloride 0.1% Eye Drops as the documentation did not meet the prior authorization requirements. 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 Tadalafil 5 milligram tablets prescribed as need for erectile dysfunction. 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 also researched Medicare systems and reviewed the enrollment data available. We determined that the plan is not required to cover Tadalafil. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. 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 Megestrol Acetate Suspension 625-milligrams/15-milliliters to treat cachexia secondary to malignant neoplasm left kidney except renal pelvis. 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

At issue is a request for coverage of Humira 40 milligram per 0.4 milliliter subcutaneous injection pen kit. 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 Humira has been prescribed for sarcoidosis with cardiac and pulmonary involvement, and neurosarcoidosis. However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications 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 the Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 3% gel. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation submitted does not contain medical records or a prescribed diagnosis. A request for medical records and a supporting statement was sent to your doctor; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Viberzi 75 milligram tablet prescribed twice daily for irritable bowel syndrome with diarrhea. 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. A physician reviewed your appeal and determined that the plan is not required to cover Viberzi.