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

At issue is Olumiant 2 milligram tablet to treat alopecia areata. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The plan has prior authorization coverage criteria that must be met prior to approval. The criteria indicates the enrollee must have a Food and Drug Administration approved indication. The submitted medical records indicate a diagnosis of severe form of alopecia areata and the Medicare approved compendia contain a citation to support the use of the drug for the enrollees noted diagnosis. Therefore, the requested drug(s) is eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Entresto 24 milligram (mg)  26 mg tablet to treat chronic right heart failure. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Entresto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cinacalcet Hydrochloride 30 milligram tablet. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support a diagnosis and to support the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation does not include medical records or clinical evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. 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 Hetlioz 20 milligram capsule to treat circadian rhythm sleep disorder, free running type non-24 hour. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber to address the prior authorization criteria. However, we did not receive the requested information.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.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 Hetlioz 20 milligram capsule to treat non-24 hour sleep wake disorder. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber to address the prior authorization criteria. However, we did not receive the requested information.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.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 a tiering exception request for Kisqali 200 milligram tablets to treat metastatic breast cancer, HR positive, HER2 negative. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria. Of note, a tiering exception cannot be granted for a drug that has not been approved for coverage.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 Amphetamine/Dextroamphetamine 30 milligram oral tablet. The case was auto-forwarded by the plan.We received the submitted documentation to perform an independent and de novo review.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support a covered diagnosis and that the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. 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 Imvexy 10 microgram maintenance pak. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis, to clarify the medical history, to address the non-formulary exception criteria, and to provide supporting medical records. A reply from the prescriber was not received. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. 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 Sildenafil 20 milligram tablets to treat an unknown diagnosis. The case was auto-forwarded by the Part D plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested a medically accepted indication, medical records, and a prescriber statement to support that the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.No documentation was provided by the prescriber. We requested information from the prescriber but no information was received. We are not able to determine whether the requested drug(s) was prescribed for a medically accepted indication. Therefore, the drug(s) 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: Favorable

At issue is Zarxio 480 microgram per 0.8 milliliter solution to treat chemotherapy induced neutropenia. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates the prescriber ordered the drug at issue for the enrollees diagnosis. The Medicare approved compendia contain citations to support the use of the drug for the enrollee's diagnosis. As such, the submitted documentation supports the drug was prescribed for a medically accepted indication.The plan has prior authorization coverage criteria that must be met prior to approval. The enrollee satisfies the Plans coverage criteria. The documentation supports the drug at issue will be given 48 hours after chemotherapy for the prophylaxis of chemotherapy induced neutropenia. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temazepam 15 milligram capsule to treat 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee has satisfied the plans prior authorization coverage criteria. We received additional documentation and included it in the review. The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.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 Methocarbamol 750 milligram tablet to treat muscle spasms of back. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed or were contraindicated. We received additional documentation and included it in the review. The requested drug is not on the plans formulary. 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 documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Gleevec 400 milligram tablets to treat gastrointestinal stromal tumor of the stomach. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates the prescriber ordered the drug at issue for the enrollees diagnosis. The Medicare approved compendia contain a citation to support the use of the drug for the noted diagnosis. The Food and Drug Administration states the drug at issue is indicated for CD117 positive gastrointestinal stromal tumor of the stomach as adjuvant treatment or for advanced disease. As such, the submitted documentation supports the drug was prescribed for a medically accepted indication. The plan has prior authorization coverage criteria that must be met prior to approval. The enrollee satisfies the Plans coverage criteria. The criteria indicates the enrollee must have a Food and Drug Administration approved indication. The Medicare approved compendia contain a citation to support the use of the drug for the enrollees noted diagnosis. Therefore, an exception to the plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nitrofurantoin Monohydrate Macrocrystals 100 milligram capsule for urinary tract infection suppression. The case was auto-forwarded by the plan. 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 requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support a diagnosis and to support the quantity prescribed was medically necessary for the enrollee. We received additional documentation and included it in the review.The plan limits the amount of Nitrofurantoin Monohydrate to 90 tablets per 365 days. The prescriber has not submitted clinical evidence that the number of doses of the requested drug allowed by the plan was ineffective in treating the diagnosis or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. 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 Norvasc 5 milligram tablet to treat hypertension. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. 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 documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Lidocaine 5 percent patch to treat DIAGNOSIS. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including 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 diagnosis. Therefore, the requested drug(s) 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 Cutaquig 16.5 percent (2 grams per 12 milliliter) vial to treat immunodeficiency secondary to chemotherapy . The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including 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 diagnosis. Therefore, the requested drug(s) 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: Favorable

At issue is Harvoni 90/400 milligram tablet to treat chronic viral hepatitis C, genotype 1. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The drug is approved by the Food and Drug Administration, per Medicare Approved compendia, to treat the diagnosis of hepatitis C, chronic, genotype 1, treatment naive, with compensated cirrhosis. The diagnosis has been confirmed by the presence of hepatitis C virus ribonucleic acid in serum and the requested drug will be used alone. The request is for an enrollee with genotype 1, compensated cirrhosis, and enrollee is treatment naive. The enrollee has not received greater than or equal to 12 weeks of treatment with the requested drug. A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram per milliliter syringe to treat hyperlipidemia in patients with clinical atherosclerotic cardiovascular disease. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria. Therefore, the patient has not met the coverage criteria.  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 Kisqali 600 milligram tablets to treat advanced breast cancer, HR positive, HER2 negative. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Promacta 25 milligram tablet for persistent idiopathic thrombocytopenia. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation satisfies the plans coverage criteria. The documentation supports a diagnosis of persistent idiopathic thrombocytopenia. The enrollee had completed a steroid taper and also required 2 platelet infusions and had another fall in the platelet count. Another round of prednisone therapy was completed but the therapy did not sustain and failed. The laboratory studies submitted show a fall in the platelet count to 47000 per microliter. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligram per milliliter solution prefilled syringe to treat age related osteoporosis without current pathologic fracture. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.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 Eplerenone 50 milligram tablet to treat chronic combined systolic and diastolic congestive heart failure. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. 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 documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Testosterone 30 milligram per actuation solution. The Part D plan denied the request.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. 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 Yuvafem 10 microgram vaginal insert to treat postmenopausal atrophic vaginitis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. 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 documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.