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

At issue is Rytary 48.75 to 195 milligram extended-release oral capsule prescribed daily for Parkinson disease. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Rytary 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

At issue is Repatha 140 milligrams per milliliter syringe prescribed for the enrollees condition. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an auto-forwarded reconsideration request from the coverage level.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. We requested medical records and a prescribers statement from the physician to determine the enrollee's diagnosis and validate that the plan's prior authorization coverage criteria had been met. However, the physician did not submit medical records or a prescribers statement. Therefore, the enrollee has not satisfied the plan's coverage criteria.  A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gralise 600 milligram extended-release oral tablet prescribed daily for post-herpetic neuropathy.  The Part D plan denied your request because the National Drug Code submitted for this drug indicates it is not a Food and Drug Administration approved drug. 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 information in the case file submitted indicates that National Drug Code 13913-005 was submitted; this is a Food and Drug Administration approved medication. We have confirmed that this National Drug Code is for Gralise 600 milligram tablet, a drug that is Food and Drug Administration approved.The drug is being prescribed for a medically accepted indication. However, 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. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tretinoin 0.025% cream prescribed daily for actinic keratosis. The Part D plan denied your request because the provided diagnosis is a non-medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber statement shows Tretinoin was prescribed to treat actinic keratosis of the scalp. However, the Medicare approved compendia do not support the use of this drug for this condition. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Tretinion.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Calcipotriene 0.005% cream. The Part D plan denied the request stating that the medication was prescribed for a non-medically accepted indication. 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 documentation indicates the Calcipotriene cream has been prescribed for the treatment of actinic keratosis in combination with Fluorouracil cream. However, 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 your appeal and determined that the plan is not required to cover the Calcipotriene cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira Pen 40 milligrams/0.4 milliliters prescribed for sarcoidosis with pulmonary and cardiac involvement. The Part D plan denied your request because the diagnosis provided does not meet the requirements of a Food and Drug Administration medically accepted indication for an off-label use. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Humira to treat your sarcoidosis with pulmonary and cardiac involvement. However, the Medicare approved compendia do not support the use of this drug for your condition. As such, the off-label use for Humira cannot be approved. A physician reviewed your appeal and determined that the plan is not required to cover Humira Pen because your diagnosis does not meet the Medicare requirement of a medically accepted indication for an off-label use.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 10 milligram tablets to treat skeletal muscle spasm associated with chronic musculoskeletal conditions.   The Part D plan denied your request because the documentation did not support an off-formulary exception.  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 provided medical records from date of service 2/18/2021 with the request for reconsideration.  These medical records document the following diagnoses:   sacroiliitis, lumbar radiculopathy, lumbar post-laminectomy syndrome, cervical spondylosis, cervical radiculopathy and cervical spinal stenosis.  The  use of the requested drug to treat the provided diagnoses 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 these conditions.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligram tablets prescribed for psoriatic arthritis. The Part D plan denied coverage because prior authorization is required before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation supports Otezla was prescribed for psoriatic arthritis which is a medically accepted indication. However, the documentation provided does not show that the enrollee has satisfied the plan's prior authorization coverage criteria. A physician reviewed your appeal and determined that Otezla is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humalog Kwikpen mix 75/25 prescribed as directed for type 2 diabetes mellitus. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an auto-forwarded 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 record shows that your doctor prescribed the Humalog Kwikpen to treat your condition. Your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Humalog Kwikpen because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Itraconazole 100 milligram capsules prescribed for pulmonary aspergillosis. The Part D plan denied your request for a tiering exception because Itraconazole is a Tier 4 drug and there are no drugs on the lower cost-sharing tiers to treat your condition. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The record shows Itraconazole is being prescribed for pulmonary aspergillosis. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Itraconazole is a Tier 4 drug. There are no drugs on the lower cost-sharing tiers to treat your condition. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Flexeril 5 milligram tablets prescribed daily for osteoarthritis of hip, unspecified laterality, unspecified osteoarthritis type. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Flexeril for osteoarthritis of hip, unspecified laterality, unspecified osteoarthritis type. In review of the Medicare approved compendia, osteoarthritis of hip, unspecified laterality, unspecified osteoarthritis type is not a medically accepted indication for Flexeril. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Flexeril at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Octreotide Acetate 50 micrograms/milliliter solution was prescribed to treat the diagnosis of upper gastrointestinal bleeding due to small bowel angeioectasis. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 your 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

You requested Dronabinol 2.5 milligram capsules prescribed for unspecified nausea with vomiting, gastroparesis, and anorexia. The Part D plan denied your request because the drug requires prior authorization and was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows the doctor prescribed Dronabinol to treat unspecified nausea with vomiting, gastroparesis, and anorexia. The documentation does not show that the medication was prescribed to treat nausea and vomiting within 48 hours after chemotherapy. The Medicare approved compendia do not support the use of this drug for the enrollees condition. Since the drug was not prescribed for a medically accepted indication, the drug is not covered by Part D. As such, the prior authorization criteria have not been considered for review.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine Pamoate 100 milligram tablet prescribed three times a day as needed for anxiety. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Hydroxyzine Pamoate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulicity 1.5 milligrams/0.5 milliliter prescribed for Type 2 diabetes mellitus. The plan denied the appeal because this drug is not listed on your formulary plan (non-formulary). We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The records show your doctor prescribed Trulicity for your Type 2 diabetes mellitus. This drug is not listed in your plans formulary for your condition. Your doctor did not indicate that you tried all the drugs listed on your plans formulary for your condition, why they did not work just as well, or that they caused adverse effects. Therefore, the requested drug cannot receive a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Trulicity because the documentation does not show that you have met the coverage criteria for a formulary exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80 milligrams/milliliter auto-injector to treat chronic plaque psoriasis. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Taltz. A physician reviewed your appeal and determined that the plan is not required to cover Taltz because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligrams prescribed each night for insomnia. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of insomnia. However, the enrollee does not 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: Unfavorable

At issue is Humira pen injector 40 milligrams. At initial determination and redetermination the diagnosis of takayasu arteritis was given. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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. At reconsideration a diagnosis of rheumatoid arthritis was given. No medical records were provided by the prescriber to support this diagnosis. The requested drug was is not a medically accepted indication for the diagnosis provided. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil Citrate 100 milligram capsules prescribed for the enrollees condition. We received an auto-forwarded reconsideration request from the coverage level. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.The record shows the physician ordered Sildenafil 100 milligrams. We requested medical records and a diagnosis from the physician. The Part D plan is responsible for ensuring that covered Part D drugs are prescribed for medically accepted indications. We did not received any medical records from the physician stating what condition the medication is being prescribed for. Therefore, there is insufficient information to determine if the Sildenafil Citrate is being prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover the Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligrams prescribed one table daily for irritable bowel syndrome with diarrhea. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Your doctor prescribed Xifaxan to treat your condition. Medicare approved compendia do support the use of this drug for your condition. However, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria. Namely, the prior authorization requires that you had not had an initial 14-day course of treatment and two additional 14-day courses. A physician reviewed your appeal and determined that the plan is not required to cover Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested the off-formulary drug Airduo Respiclick 232-14 micrograms prescribed one puff twice a day for severe persistent asthma. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. Your physician submitted a prior authorization form only. 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 reimburse you for the Airduo Respiclick.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Megestrol Acetate 40 milligram tablets prescribed daily for end stage renal disease and protein-calorie malnutrition. The Part D plan denied your request because the provided diagnoses do not meet the criteria of a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Megestrol Acetate 40 milligram tablets to treat your end stage renal disease and protein-calorie malnutrition. 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 Megestrol Acetate because it was not prescribed for a medically accepted indication.