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

At issue is Otrexup 25 milligram/0.4 milliliter solution auto injector prescribed as directed for systemic sclerosis unspecified with moderate to severe 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. 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 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 an addendum added to the medical records on 8/3/2021, the prescriber states the enrollee has a diagnosis of seronegative rheumatoid arthritis in addition to systemic sclerosis.  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 provided documentation does 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 Otrexup.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Duragesic 75 microgram/hour 72 hour patch.  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 Flovent HFA 220 microgram inhalation prescribed as directed for esophageal lichen planus. 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 Flovent HFA  to treat your esophageal lichen planus. However, the Medicare approved compendia do not support the use of this drug for your condition. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules. A physician reviewed your appeal and determined that the plan is not required to cover Flovent HFA.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Nucala 100 milligram/milliliter auto-injector prescribed for severe asthma, unspecified type. The Part D plan denied the request because the diagnosis submitted is not a medically accepted indication. In addition, the requested drug is not included on the plans formulary.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 the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. However, we did not receive the documentation. The documentation shows Nucala was prescribed to treat severe asthma. However, the Medicare approved compendia do not support the use of this drug for your condition. Since the drug is not eligible for coverage under Part D, the plans formulary exception requirements are not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover Nucala.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doxepin Hydrochloride 5% cream prescribed to treat an enrollee with chronic pain syndrome (not complex regional pain syndrome) and lumbar radiculopathy. 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.The documentation shows the doctor prescribed Doxepin Hydrochloride 5% cream to treat chronic pain syndrome (not complex regional pain syndrome) and lumbar radiculopathy.  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 Doxepin Hydrochloride 5% cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cyclobenzaprine Hydrochloride 5 milligram tablets. 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 prescriber has indicated that Cyclobenzaprine Hydrochloride is being used for the treatment of cervical spinal stenosis. 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 chronic 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 Kesimpta 20-milligrams/0.4-milliliter Subcutaneous Pen to treat primary progressive multiple sclerosis. The Part D plan denied the request. 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 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 specific condition.  Therefore, the requested drug, as ordered, is not being used for a medically accepted indication. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules. The requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Promethazine Hydrochloride 25 milligram tablets. The Part D plan denied the request for coverage because the medication was being used for a non-medically accepted indication. 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 diagnosis initially provided to the plan was nausea due to cluster headaches. However, the Medicare approved compendia do not contain any citations to support the use of Promethazine Hydrochloride for the treatment of this condition.At reconsideration, the prescriber has requested to change the diagnosis to nausea induced by the enrollees current medication panel. However, the Medicare approved compendia do not contain any citations to support the use of Promethazine Hydrochloride for the treatment of this condition.Therefore, the requested drug is being prescribed for non-medically accepted indications. As such, the requested drug 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 Stelara 90 milligram/milliliter injection prescribed as directed for ulcerative necrobiosis lipoidica. 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 Stelara to treat your ulcerative necrobiosis lipoidica. However, the Medicare approved compendia do not support the use of this drug for your condition. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules. A physician reviewed your appeal and determined that the plan is not required to cover Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 50-milligram tablet to treat an unknown condition. The Part D plan denied the request. 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.We asked your prescriber to send us medical records verifying a medically accepted indication (diagnosis). However, we did not receive the documentation.At reconsideration a diagnosis of benign prostatic hyperplasia was given. No medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Tymlos 3120 micrograms per 1.56 milliliter dose pen prescribed 80 micrograms daily for age-related osteoporosis with a history of fractures. 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 Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Gabapentin 60 millgram tablet prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee requested the plan to provide reimbursement for Gabapentin 60 millgram tablet filled on April 14, 2021. However, Medicare records indicate that the enrollee was not enrolled with the Part D plan for date of service April 14, 2021. Therefore, we determined that the plan is not required to provide reimbursement for this date of service. The dates of service May 10, 2021 and June 4, 2021 were submitted and processed for an amount that is less than or equal to the required copayment amount. Therefore, no additional reimbursement is required by the plan for these dates of service.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 50 milligram tablet prescribed daily. The Part D plan denied the request for a tiering exception.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. Myrbetriq ER 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% gel pump prescribed for hypogonadism. 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 documentation shows Testosterone 1.62% gel pump is prescribed to treat hypogonadism. 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 Testosterone 1.62% gel pump.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tacrolimus 1 milligram capsule prescribed for a kidney transplant recipient. 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. Medicare systems show that your kidney transplant was not a Medicare Part A covered procedure. This drug is eligible under Part D drug benefits. Medicare approved compendia supports the use of this drug for the reported condition.  A physician reviewed your appeal and determined that the plan is required to cover Tacrolimus 1 milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 1% Gel to treat bilateral low back pain. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Tyvaso refill solution 0.6 milligram/milliliter prescribed for the treatment of pulmonary hypertension. The Part D plan denied the enrollees request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the Tyvaso refill solution 0.6 milligram/milliliter is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Tyvaso refill solution 0.6 milligram/milliliter. Please consider submitting this 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

At issue is a request for coverage of Lidocaine 5% patches. The Part D plan denied the request for coverage because the medication was being used for a non-medically accepted indication. 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 initially submitted to the plan indicates that Lidocaine 5% patches were prescribed for the treatment of low back pain due to scoliosis. At reconsideration, the newly submitted documentation indicates that Lidocaine 5% patches were prescribed for pain after cancer treatment and pain due to osteopenia. During this review, a request was sent to the prescriber to clarify what condition(s) the Lidocaine patches were being prescribed for and to provide supporting medical records. However, the prescriber did not respond. Therefore, there is insufficient documentation to validate whether the requested drug is being prescribed for a medically accepted indication outlined in the Medicare approved compendia. As such, the drug 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 a request for coverage of Taltz 80 milligram per milliliter prefilled syringe prescribed for the treatment of plaque psoriasis. 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. Taltz is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Evamist 1.53-milligram/Spray to treat menopausal and female climacteric states. The Part D plan denied the request. The requested drug is not on the plans formulary. 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.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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 milligram tablets. The Part D plan denied the appeal request for a tiering exception.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.Jardiance 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone Hydrochloride Extended Release 40 milligram tablet prescribed for chronic 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 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. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to 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. A physician reviewed your appeal and determined that the plan is not required to cover  Oxycodone Hydrochloride Extended Release tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Durezol 0.05 percent eye drops prescribed as directed for post glaucoma surgery. 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. The documentation shows the doctor prescribed Durezol post glaucoma surgery. The plan has step therapy 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 Durezol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Horizant Extended Release 300-milligram tablet to treat lumbar spondylosis. 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 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.