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

At issue is Belsomra 15 milligram tablet prescribed daily for insomnia. 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.Belsomra 15 milligram tablet is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz XR 11 milligram tablet prescribed for ankylosing spondylitis. 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 Xeljanz XR 11 milligram tablet to treat the enrollees ankylosing spondylitis. 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 Xeljanz XR 11 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100-62.5-25 micrograms for inhalation prescribed for chronic obstructive pulmonary disease. 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. Trelegy Ellipta is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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 a request for coverage of Testosterone 1.62% gel pump prescribed for primary hypogonadism. 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.Testosterone 1.62% gel pump is not included in the plans formulary. At reconsideration, the prescriber has noted that the injectable forms of Testosterone are contraindicated for this enrollee because the enrollee has a history of drug abuse and schizophrenia. The prescriber explains that due to these issues, it is not safe for the enrollee to have access to needles. The submitted medical records support the diagnosis of schizophrenia and history of drug dependence. However, the formulary does include an oral form of Testosterone. The prescriber has not addressed why the oral form of Testosterone would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans 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 Calquence 100 milligram capsules prescribed for hairy cell leukemia. 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 Calquence to treat your hairy cell leukemia. 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 Calquence.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tobramycin 300 milligrams pre 5 milliliter vial via nebulizer prescribed every 12 hours for sinusitis due to pseudomonas. 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 drug is eligible for coverage under Medicare Part B. However, the prescriber states the diagnosis is not allowed by Part B. The documentation shows the doctor prescribed Tobramycin via nebulizer to treat the enrollees sinusitis. 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 Tobramycin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Opsumit 10 milligram tablets prescribed to treat the diagnosis of pulmonary arterial hypertension. 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 your doctor prescribed Opsumit 10 milligram tablets to treat your condition. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The prescriber has not sufficiently addressed the plans coverage criteria and/or the provided medical records do not satisfy the coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage. The documentation does not satisfy the plans coverage criteria.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine 5% ointment. At initial determination and redetermination, the diagnoses of unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder; neuropathy; and lumbar disc disease is given. 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 Lidocaine 5% ointment has been prescribed for lumbar disc disease and neuropathy. However, the Medicare approved compendia do not contain any citations to support the use of Lidocaine 5% ointment, 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 Lidocaine 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nourianz 20 milligram tablets prescribed daily for Parkinsons 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. We also researched Medicare systems and reviewed the enrollment data available. 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 Nourianz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alprazolam 0.25 milligram tablet prescribed twice daily for essential tremor. 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 Alprazolam to treat your essential tremor. 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 Alprazolam.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Donepezil Hydrochloride 5 milligram tablets prescribed twice daily for memory loss. 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 Donepezil Hydrochloride for memory loss. 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

At issue is Xifaxan 550 milligram tablets prescribed three times daily for irritable bowel syndrome with diarrhea. 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. We also researched Medicare systems and reviewed the enrollment data available. This drug is included on Tier 5 of the plans formulary. This Tier is identified as a Specialty Tier. The plan is not required to grant a tier exception for drugs available on their Specialty Tier. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine HCL 10 milligram tablet prescribed for chronic 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. The documentation shows was prescribed to treat chronic back pain. 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 Cyclobenzaprine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Antacid 200-200-20 milligram/5 milliliter Oral Suspension prescribed for chemotherapy induced mucositis. The Part D plan denied your request. The QIC notes this drug is being requested as part of a compounded drug.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 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 drug is a non-prescription or over-the-counter (OTC) drug. Therefore, Antacid Oral Suspension ingredients are not eligible for Part D coverage. The plan is not required to cover them. This decision does not address the medical necessity of this drug. It only means that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested M-Dryl 12.5 milligram/5 milliliter Oral Liquid prescribed for chemotherapy induced mucositis. The Part D plan denied your request. The QIC notes this drug is being requested as part of a compounded drug.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 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 drug is a non-prescription or over-the-counter (OTC) drug. Therefore, M-Dryl Oral Liquid is not eligible for Part D coverage and the plan is not required to cover it. This decision does not address the medical necessity of this drug. It only means that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligram tablets prescribed for insomnia. 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 Zolpidem Tartrate to treat your insomnia. 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 Zolpidem Tartrate. The records submitted indicate the non-high risk medication, doxepin, was tried but also indicate there was no intolerance or inadequate treatment response to that drug or reason why it was not used. 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 Spiriva Respimat 1.25 microgram inhalation prescribed for asthma. 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.Spiriva Respimat is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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 a request for coverage of Northera 100 milligram capsules. 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 Northera has been prescribed in the management of the enrollees neurogenic orthostatic hypotension, which is present as a result of the hypothalamic involvement of a chondrosarcoma at the skull base and the radiation treatment received for the tumor. While the Medicare approve compendia list neurogenic orthostatic hypotension as an acceptable indication for the use of Northera, the compendia specify that it is acceptable in cases of neurogenic orthostatic hypotension which have been caused by primary autonomic failure, dopamine beta-hydroxylase deficiency, or nondiabetic autonomic neuropathy. The records do not support the enrollees neurogenic orthostatic hypotension is being caused by primary autonomic failure, dopamine beta-hydroxylase deficiency, or nondiabetic autonomic neuropathy. 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 your appeal and determined that the plan is not required to cover the Northera.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gilenya 0.5 milligram capsule prescribed for relapsing remitting 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. The prescriber submitted a statement and medical records that support Gilenya was prescribed to treat relapsing remitting multiple 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 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 Gilenya
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 145 microgram capsules prescribed for constipation. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Linzess is a brand name drug on Tier 4 of the plans formulary. There are no brand name 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 Gocovri 137 milligram ER capsules prescribed for dyskinesia in an enrollee with Parkinsons. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your physician submitted a supporting statement. The statement does not support that you satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Fentanyl 25 microgram per hour transdermal patches. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. During this review, a prescriber statement was requested and received. We reviewed all documentation submitted.The submitted medical records and prescriber statement indicate that Fentanyl transdermal patches have been prescribed for chronic, severe low back and rib pain due to multiple myeloma bone lesions. The records show that the enrollee is being treated for pancreatic cancer and multiple myeloma not having achieved remission. The prescribing physician has noted that the enrollee has tried and failed Oxycontin IR 10 milligrams, Oxycodone IR 5 milligrams, Norco 10/325 milligrams, and Ultram 50 milligrams over the last two years. The plan has no prior authorization requirements for the coverage of Fentanyl transdermal patches, and the medical records support that the Fentanyl is being prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the plan is required to cover the Fentanyl transdermal patches.
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.  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 the Lidocaine 5% patches have been prescribed for chronic neuropathic pain due to the presence of type 2 diabetes and chronic musculoskeletal pain. 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 Lidocaine 5% patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Adderall XR 15 milligram capsule prescribed to treat the enrollees condition. 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 Adderall XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec 75 milligram disintegrating tablets prescribed for migraine with aura, not intractable, without status migrainosus. 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 all the 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 Nurtec.