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

At issue is Sildenafil Citrate 20 milligram tablet to treat secondary pulmonary hypertension in an enrollee with ischemic cardiomyopathy who is receiving treatment with a left ventricular assist device. 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 Sildenafil Citrate was prescribed to treat secondary pulmonary hypertension in an enrollee with ischemic cardiomyopathy who is receiving treatment with a left ventricular assist device.. 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 Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aubagio 14 milligram tablets prescribed as directed for multiple sclerosis. 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 Aubagio.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise 600 milligram tablet prescribed for numbness and tingling of the feet most likely caused by chemotherapy due to ovarian cancer. 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 medical records indicate that Gralise 600 milligram tablet is prescribed for numbness and tingling of the feet most likely caused by chemotherapy due to ovarian cancer. However, 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 Gralise.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Testosterone 1.62 percent gel pump prescribed for the treatment of primary hypogonadism. 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 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.  Relevant medical records were requested but not provided.  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 Emgality solution 10 milligram/milliliter auto-injector to treat cluster headache syndrome.  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 prescriber has provided a statement and medical records. However, the documentation does not address why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. 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

At issue is Actemra ACTpen 162 milligrams per 0.9 milliliters prescribed subcutaneously every 14 days for systemic sclerosis. 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 show the prescriber ordered Actemra ACTpen 162 milligrams per 0.9 milliliters to treat the enrollees systemic sclerosis. Actemra ACTpen has an orphan drug designation per the Micromedex compendium and therefore is considered a medically accepted indication per Medicare guidance. However, 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 the appeal and determined that the plan is not required to cover Actemra ACTpen 162 milligrams per 0.9 milliliters. 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 Rivastigmine 4.6 milligram/24-hour patch prescribed as directed for mild cognitive impairment. 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 Rivastigmine to treat your mild cognitive impairment. 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 Rivastigmine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mugard Liquid prescribed for oral mucositis following chemotherapy. 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 determined that the plan is not required to cover the Mugard Liquid. Mugard Liquid adheres to the mucosal surface of the mouth forming a protective film or coating over the irritated areas and lesions, protecting the lesion from further irritation and pain like a dressing, and is considered a device by the Food and Drug Administration. Therefore, Mugard Liquid is excluded from coverage under Medicare Part D. The decision does not address medical necessity. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligram tablets to treat erectile dysfunction. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sofosbuvir-Velpatasvir 400-100 milligram tablet to treat chronic hepatitis C. 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. 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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Sofosbuvir-Velpatasvir.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Botox 200 units reconstituted solution prescribed to treat the diagnosis of intractable chronic migraine. The Part D plan denied the appeal 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 for the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Botox 200 units reconstituted solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 3-percent gel prescribed for varicose veins of bilateral lower extremities with other complications. 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 submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a prior authorization request for Repatha 140-milligram/milliliter injection solution prescribed for primary hyperlipidemia in an enrollee with coronary artery disease. The Part D plan denied coverage.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 records submitted at the reconsideration level. The enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee was prescribed the biologic at issue for the noted condition. The prescriber indicates this is a continuation of treatment and the enrollee has had documented LDL-cholesterol reduction while on Repatha therapy. The submitted documentation includes laboratory results to support a reduction in LDL-cholesterol from 172-milligrams/deciliter to 146-milligrams/deciliter. The plans prior authorization coverage criteria has been met.A physician reviewed the appeal and determined that the requested biologic is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone Hydrochloride 20 milligram extended release tablets prescribed for cancer-related 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 information submitted at the reconsideration level.This medication is not on your plan's list of medications. The prescriber has not given a clear and valid 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. A physician reviewed the appeal and determined that the plan is not required to cover Oxycodone Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brilinta 90 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. Brilinta 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 Nuedexta (dextromethorphan 20 milligrams with quinidine 10 milligrams) prescribed as directed for pseudobulbar affect. 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 Nuedexta to treat your pseudobulbar affect. 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 brequired to cover Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Caplyta 42-milligram capsules prescribed for post-traumatic stress disorder with unspecified psychosis. 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 submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 Rinvoq 15 milligram tablets prescribed as directed for rheumatoid arthritis. 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 Rinvoq.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Promacta 50-milligram 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 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 prescribing physician has indicated that the Promacta is being prescribed for the treatment of thrombocytopenia due to multiple underlying factors including Kabuki syndrome, Evans syndrome, and autoimmune disease. The diagnosis of thrombocytopenia does not appear in the medical records provided. 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 Kevzara 200 milligram/1.14 milliliter prefilled syringe injection to treat rheumatoid arthritis.  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.The prescriber has provided a statement and medical records. However, the documentation does not address why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. 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

At issue is OxyContin ER 10 milligram tablets prescribed as directed for low back pain. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. 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 OxyContin ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablets to treat postural orthostatic hypertension. 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 Corlanor was prescribed to treat postural orthostatic hypertension. 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 Corlanor.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Zolpidem Tartrate 5 milligram tablet to treat primary insomnia. 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 plan requires for continuation of Zolpidem Tartrate that the enrollee has tried the non-High Risk Medication alternative drug Doxepin (3 mg or 6 mg). The documentation includes a prescriber statement and clinical notes which satisfied the plan's coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Esomeprazole Magnesium DR 40-milligram delayed release capsules, 60 capsule per 30 days, prescribed for the treatment of gastroesophageal reflux disease. The Part D plan denied the request for 60 capsules per 30 days.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 plans quantity limit for the requested drug is 30 capsules per 30 days. The submitted documentation does not include a prescriber statement or medical records that sufficiently address whether the enrollee tried the formulary quantity limit and it did not work; if there is a medical reason why the enrollee cannot use the formulary quantity limit; and/or if the amount of drug allowed by the plan is not effective or likely to be ineffective. Therefore, the documentation does not support an exception to the plans quantity limit criteria. A physician reviewed the appeal and determined that the plan is not required to cover more than 30 capsules of Esomeprazole Magnesium DR per 30-day supply.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gelsyn-3 Intra-articular 16.8 milligram/2 milliliter solution prefilled syringe prescribed for unilateral primary osteoarthritis of the left knee. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 determined that the plan is not required to cover the requested drug. Gelsyn-3 is a drug that is injected into the knee and is considered a device by the Food and Drug Administration. Therefore, the device does not meet the definition of a Part D drug, and is excluded from coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cinacalcet Hydrochloride 30 mg tablet prescribed as directed for secondary hyperparathyroidism. 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 Cinacalcet Hydrochloride to treat your secondary hyperparathyroidism.. 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 Cinacalcet Hydrochloride.