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

At issue is Mavyret 100/40 milligram tablet prescribed three times daily for chronic hepatitis C virus. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The medical records support the doctor prescribed Mavyret to treat the enrollees chronic hepatitis C virus. 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 Mavyret. The medication must be prescribed by or in consultation with a gastroenterologist, hepatologist, infectious disease physician, or liver transplant physician. 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 Neupro 8 milligram 24 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.Neupro 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 Reclast 5-milligrams/100-milliliters to treat postmenopausal osteoporosis. 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.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

At issue is Buprenorphine Hydrochloride tablet sublingual 2 milligram, a quantity of 30 tablets per 30 days prescribed for chronic pain syndrome. 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 record shows a diagnosis of chronic pain syndrome and supports that the doctor prescribed Buprenorphine Hydrochloride tablet(s) sublingual 2 milligram to treat the enrollees pain. However, the Medicare approved compendia do not support the use of this specific drug in tablet form for the enrollees condition(s). A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride tablet(s).
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lynparza 100 milligram tablets prescribed for metastatic melanoma. 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 Lynparza for metastatic melanoma. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There are no Medicare approved journal articles to support the use of the drug 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 Diclofenac 1% Gel to treat left shoulder pain due to osteoarthritis. 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug. 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 Humalog 100 units per milliliter kwikpen prescribed 40-70 units subcutaneously before meals for type 2 diabetes mellitus with hyperglycemia. 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 asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work. A physician reviewed the appeal and determined that the plan is not required to cover Humalog 100 units per milliliter kwikpen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed daily for neck 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. The documentation shows the Enrollees doctor prescribed Lidocaine patch to treat the Enrollees neck pain. However, the Medicare approved compendia do not support the use of the requested drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover the Lidocaine patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine 2 milligram sublingual tablet to be given twice daily for chronic pain syndrome, low back pain, lumbar radiculopathy, and lumbar post-laminectomy syndrome. The Part D plan denied the drug.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 Buprenorphine 2 milligram sublingual tablet to treat the enrollees chronic pain syndrome, low back pain, lumbar radiculopathy, and lumbar post-laminectomy syndrome. The Medicare approved compendia do not support the use of this drug formulation for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to cover the Buprenorphine 2 milligram sublingual tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Viagra 100 milligram tablet prescribed for erectile dysfunction. The Part D plan denied the request. We performed and 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 Viagra because it was used to treat sexual or erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, they must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Retacrit 10000 international unit/ milliliter vial prescribed for anemia associated with chronic renal failure in an enrollee not on dialysis. The Part D plan denied your request as the prior authorization requirements were not met.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. Your physician indicates the enrollees dose will not be reduced or interrupted if the enrollees hemoglobin exceeds 10 grams/deciliters. Medicare approved compendia do not support the use of this drug for your condition when the dose will not be reduced or interrupted for a hemoglobin greater than 10 grams/deciliters. A physician reviewed your appeal and determined that the plan is not required to cover Retacrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Flector 1.3% patch prescribed for chronic 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.The submitted documentation indicates the prescriber ordered Flector patches for chronic low back pain. The Medicare approved compendia do not support the use of the drug at issue for your condition. As the drug was not 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 Taltz Solution Auto-Injector 80 milligram/milliliter prescribed for hidradenitis suppurative. 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 prescriber indicates the enrollee has been prescribed Taltz Solution Auto-Injector 80 milligram/milliliter to treat hidradenitis suppurative. 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 Taltz Solution Auto-Injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Austedo 9-milligram tablet to treat tardive dyskinesia. 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.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

At issue is a tiering exception request for Repatha Sureclick 140 milligram/milliliter injection prescribed for the enrollees condition. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Repatha Sureclick is a biologic on Tier 3 of the plans formulary. There are no biologics of the same type on the lower cost sharing tiers. Therefore, this biologic 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 a request for coverage of Procrit 40,000 units per milliliter solution for subcutaneous injection prescribed for an enrollee who is anemic to optimize the enrollees hemoglobin level prior to knee replacement surgery. 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 Part D plan has prior authorization requirements that must be met before coverage of this medication will be approved for the noted condition. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Zolpidem Tartrate 10 milligram tablets prescribed for the enrollees condition. 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 does not include medical records to support a covered diagnosis. A request for information was sent to the prescriber; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pradaxa 150 milligram capsule prescribed to treat atrial fibrillation. 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 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 has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plans prior authorization requirements include that for the diagnosis of atrial fibrillation, the Enrollee must have tried Eliquis or Xarelto. The prescriber indicates the Enrollee has not tried Eliquis or Xarelto. Therefore, the plans prior authorization requirements were not met.  A physician reviewed your appeal and determined that the plan is not required to cover Pradaxa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Breztri Aerosphere 160-9-4.8-micrograms/Activation Aerosol to treat chronic obstructive pulmonary disease and pulmonary emphysema. 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.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

At issue is Austedo 12-milligram tablet to treat tardive dyskinesia. 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.At reconsideration the diagnosis of right hemichorea was given. The diagnosis is not a medically accepted indication. The documentation provided addressed the plans coverage criteria, and those criteria were not satisfied. 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 Stelara 90 microgram subcutaneous prescribed as directed for Crohn's disease of small intestine without complications. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. 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 this medication. We did not receive the documentation requested.The documentation shows your doctor prescribed Stelara to treat your Crohn's disease of small intestine without complications. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation was not provided to 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 Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablets prescribed for paroxysmal atrial fibrillation. 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. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the enrollees 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 cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed for chronic pain secondary to post-laminectomy syndrome. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read 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 your doctor prescribed Lidocaine 5% patch to treat your chronic pain secondary to post-laminectomy syndrome. 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 Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Victoza 18 milligram per 3 milliliter pen-injector. 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.Victoza 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 Apriso 0.375 milligram capsule prescribed for ulcerative colitis. 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. The prescriber does not state why all other drugs on the plans formulary would not work. A physician reviewed your appeal and determined that the plan is not required to cover Apriso.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 10 milligram tablet prescribed for a personal history of traumatic brain injury and fibromyalgia. 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 prescriber indicates the enrollee has been prescribed Cyclobenzaprine 10 milligram tablet for musculoskeletal discomfort in an enrollee with fibromyalgia and a personal history of traumatic brain injury. The records do not support an acute musculoskeletal condition. 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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xiidra 5% Opthalmic Drops prescribed for dry eye syndrome. 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 you. A physician reviewed your appeal and determined that the plan is not required to cover Xiidra Opthalmic drops.