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

You requested Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed for muscle spasms. 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. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation did not contain medical records. A request for information was sent to the prescriber. However, no medical records were submitted for review. 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

You requested Hydrocodone/Acetaminophen 5-325 milligram prescribed every eight hours as needed for unknown diagnosis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization 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 your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Quinine Sulfate 324 milligram capsules prescribed for muscle spasms. 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. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation did not contain medical records. A request for information was sent to the prescriber. However, no medical records were submitted for review. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.  Also note that the Medicare approved compendia DrugDex states,  'Qualaquin(R) (quinine sulfate oral capsule) is not approved for prophylaxis or treatment of nocturnal leg cramps. Use has been associated with serious and life-threatening hematological adverse events (eg, thrombocytopenia, hemolytic-uremic syndrome/thrombotic thrombocytopenia purpura), with some cases resulting in chronic renal impairment, hospitalization, and death. Other serious adverse reactions have occurred, including hypersensitivity reactions, QT prolongation, and serious cardiac arrhythmias, including torsade de pointes. The risk associated with the use of quinine outweighs the benefits for the treatment or prevention of leg cramps. Therefore, it should not be used for the prophylaxis or treatment of nocturnal leg cramps [27].,   27. US Food and Drug Administration: FDA Drug Safety Communication: New risk management plan and patient Medication Guide for Qualaquin (quinine sulfate). US Food and Drug Administration. Rockville, MD. 2010. Available from URL: http://www.fda.go... . As accessed 2010-07-08.'A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed 60 patches every 30 days for chronic pain 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 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 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.Your medical records show your doctor prescribed Lidocaine 5% patch to treat your chronic pain syndrome.  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 Lidocaine 5% patch. You do not have a condition that meets the prior authorization criteria. 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

You requested Ondansetron Hydrochloride 4 milligram tablets prescribed for nausea due to narcotics use. 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. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation did not contain medical records. A request for information was sent to the prescriber. However, no medical records were submitted for review. 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

You requested Adacel Diphtheria, Tetanus, and Acellular Pertussis (TDAP) 2-2.5-5/.5 syringe vaccine. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your vaccine. We also asked for medical records and other documentation to show why you need this vaccine. We did not receive the documentation requested.The documentation shows you have a receipt for the Adacel TDAP vaccine and are requesting reimbursement. The Adacel TDAP vaccine is usually categorized as preventive and therefore not covered unless there is a specific covered diagnosis. In this case, no medical records were provided to support a specific covered diagnosis. We determined that the plan is not required to reimburse you for the Adacel TDAP vaccine. As such, payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 9 milligram prescribed for Crohns disease. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. 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.Your documentation supports your doctor prescribed Budesonide to treat your Crohns disease. 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 Budesonide.  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 Namzaric 28-10 milligram prescribed for unspecified dementia without behavioral disturbance. 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 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.Your medical records show your doctor prescribed Namzaric to treat your unspecified dementia without behavioral disturbance. 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 Namzaric. You must be diagnosed with Alzheimers disease and currently stabilized on Donepezil 10 milligram daily. There is no evidence that you have met the plans coverage criteria. 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 Myrbetriq 25 milligram extended-release 24-hour tablets. 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.Myrbetriq is a bran 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 Levothyroxine 25 microgram tablet prescribed for unknown diagnosis. 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. Medicare rules state that for prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must be for treatment of a condition that is completely unrelated to the terminal condition(s) or related conditions for which hospice coverage is being provided. The record shows Levothyroxine is being used for treatment of a condition that is related to hospice. We determined that the Part D plan is not required to cover the Levothryroxine. Please submit your request to Medicare Hospice benefit. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mavyret 100/40-milligram tablet prescribed 168 tablets for 56 days for chronic viral hepatitis C. 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.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 supports your doctor prescribed Mavyret to treat your chronic viral hepatitis C. 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 Mavyret. Without medical records, we are unable to determine if you have met the prior authorization requirements. 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

You requested Diclofenac Epolamine 1.3% patch prescribed for chronic pain in the right knee. 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. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not contain 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: Favorable

You requested prior authorization for Venclexta 100 milligram tablets prescribed as directed for acute myeloid 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. Your medical records show your doctor prescribed Venclexta to treat your acute myeloid leukemia. You were initially diagnosed with polycythemia vera and treated with phlebotomy and hydrea. It was then found that you have secondary myelofibrosis. In 2019, you had markedly elevated white blood cells and splenomegaly that was treated with Jakafi and Hydrea. You were hospitalized in June of 2021 and had a stroke, elevated bilirubin and transformation to acute leukemia. Vidaza was given for the past several months. The plan is to give Venclexta plus FLAG (Fludarabine, Cytarabine and Filgrastim) regimen, which has been started.Per the Food and Drug Administration and compendia, Venclexta is to be used in combination with Azacitidine, or Decitabine, or low-dose Cytarabine for the treatment of newly-diagnosed acute myeloid leukemia in adults who are age 75 years or older, or who have comorbidities that preclude use of intensive induction chemotherapy. According to the National Comprehensive Cancer Network, there is a note that if the patient has been on a hypomethylating agent already, they are less likely to get a benefit from continuing that with Venclexta. The Journal of Clinical Oncology has an article called, Venetoclax Combined with FLAG-IDA Induction and Consolidation in Newly Diagnosed and Relapsed or Refractory Acute Myeloid Leukemia, DiNardo et al. In this phase 2 study, combination therapy resulted in an increased risk of remission and potential transition to transplant. Because you have already been on Vidaza and have high risk acute myeloid leukemia (due to transformation from myelofibrosis), Venclexta in combination with FLAG regimen can be approved.A physician reviewed your appeal and determined that the plan is required to cover Venclexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is  Lumakras 120 milligram tablets prescribed for metastatic non small cell lung cancer.   The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.  The test used for Lumakras genetic testing was the Foundation One CDx test, which is not an Food and Drug Administration approved test.   The tests FDA-approved for NSCLC mutation detection for Lumakras are 'therascreen KRAS RGQ PCR Kit and Guardant360 CDx.The documentation does not satisfy the plans coverage criteria. 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

You requested Nulojix for solution 250 milligrams prescribed for renal transplant status. The Part D plan denied your request.We received a 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 record shows you received a kidney transplant on November 12, 2020. According to Medicare enrollment records, you were entitled to Medicare Part A coverage at the time of the transplant. Therefore, your transplant is considered a Medicare covered transplant and Nulojix is eligible under Medicare Part B. Therefore, we determined that the Part D plan is not required to cover the Nulojix. Please submit your request to Medicare Part B. 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

You requested Boostrix suspension 5/2.5/18.5LF-microgram/0.5 vaccine. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked the prescriber to send us information regarding your vaccine. We also asked for medical records and other documentation to show why you need this vaccine. We did not receive the documentation requested.The documentation shows you have a receipt for the Boostrix and are requesting reimbursement. The Boostrix vaccine is usually categorized as preventive and therefore not covered unless there is a specific covered diagnosis. In this case, no medical records were provided to support a specific covered diagnosis. We determined that the plan is not required to reimburse you for the Boostrix vaccine. As such, payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amlodipine Besylate 5 milligram tablet prescribed for unknown diagnosis. 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 record shows the plan reprocessed claims for the Amlodipine Besylate and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for your share of any deductible and copay. We have determined that the plan is correct in its calculation of additional copay amounts due to reconciliation of your true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Chlorthalidone 25 milligram tablet prescribed for unknown diagnosis. 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 record shows the plan reprocessed claims for the Chlorthalidone and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for your share of any deductible and copay. We have determined that the plan is correct in its calculation of additional copay amounts due to reconciliation of your true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Fiasp 100 unit/milliliter vial prescribed for unknown diagnosis. 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 record shows the plan reprocessed claims for the Fiasp and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for your share of any deductible and copay. We have determined that the plan is correct in its calculation of additional copay amounts due to reconciliation of your true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Levothyroxine Sodium 137 microgram tablet prescribed for unknown diagnosis. 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 record shows the plan reprocessed claims for the Levothyroxine Sodium and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for your share of any deductible and copay. We have determined that the plan is correct in its calculation of additional copay amounts due to reconciliation of your true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Losartan Potassium 100 milligram tablet prescribed for unknown diagnosis. 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 record shows the plan reprocessed claims for the Losartan Potassium and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for your share of any deductible and copay. We have determined that the plan is correct in its calculation of additional copay amounts due to reconciliation of your true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligrams/milliliter syringe prescribed as directed 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. Prolia 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.