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

You requested Lynparza 150 milligram tablets prescribed as directed for metastatic castrate-resistant prostate cancer. 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 the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We received the documentation and included it in our review.The medical records show the doctor prescribed Lynparza to treat metastatic castrate-resistant prostate cancer. The enrollee was initially diagnosed with prostate cancer in 2012 and found to have metastatic disease around 2016. The enrollee has been treated with Provenge and Zytiga since 2017, as well as androgen deprivation therapy. The documentation also includes genetic testing showing the presence of an ATM mutation. The following citation was referenced in the National Comprehensive Cancer Network guidelines, a Medicare approved compendium, and supports the use of this drug for the enrollees condition: useful in certain circumstances as a single-agent* for castration-resistant distant metastatic disease for patients who have been treated with androgen receptor-directed therapy and have a pathogenic mutation (germline and/or somatic) in a homologous recombination repair gene (HRRm) which include BRCA1, BRCA2, ATM, BARD1, BRIP1, CDK12, CHEK1, CHEK2, FANCL, PALB2, RAD51B, RAD51C, RAD51D or RAD54L, if Olaparib not previously received; *Continue androgen deprivation therapy to maintain castrate levels of serum testosterone (less than 50 nanograms per deciliter).The plan may cover Lynparza when prescribed for Food and Drug Administration approved indications. Lynparza is Food and Drug Administration approved for the treatment of HRR gene-mutated metastatic castrate-resistant prostate cancer. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Lynparza.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xospata 40 milligram tablet prescribed for acute myeloid leukemia with FMS-like tyrosine kinase 3 mutation. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The records show you prescribed Xospata 40 milligram tablet to treat the enrollees FMS-like tyrosine kinase 3 mutation. However, the Medicare approved compendia do not support the use of this drug for this condition. An oncologist reviewed your appeal and determined that the plan is not required to cover Xospata 40 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram capsules prescribed as directed for poor appetite related to malignant neoplasm unspecified part left bronchus/lung. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Dronabinol to treat your poor appetite related to malignant neoplasm unspecified part left bronchus/lung. However, the Medicare approved compendia do not support the use of this drug, as prescribed, for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Insulin Lispro Kwikpen 100 units/milliliter prescribed for type II diabetes. 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 includes a supporting statement from the physician. However, there were no medical records submitted to support the billed diagnosis. As the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30-milligram Tablet to treat oral lichenoid mucositis. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 this 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 Cresemba 186 milligram oral capsule prescribed daily. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber statement and medical records show Cresemba was prescribed as antifungal prophylaxis treatment secondary to acute myeloid leukemia remission. 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 Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Omega-3-acid Ethyl Esters 1 gram capsules to treat high lipid levels. The Part D plan denied your request stating that the provided diagnosis is a non-medically accepted indication. We received a reconsideration request.We performed and 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 determined that the plan is not required to cover Omega-3-acid Ethyl Esters because this drug is available over the counter (OTC). OTC drugs are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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 Cialis 20 milligram tablets to treat erectile dysfunction. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rexulti 0.5 milligram tablet prescribed daily for major depressive disorder. The Part D plan did not make a decision.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 condition. We also asked for medical records or other documentation to show why you need this amount of the medication. We did not receive the documentation requested.Your medical records show your doctor prescribed Rexulti to treat major depressive disorder. However, your medical records do not support why an exception to the plans quantity limit is medically necessary. The plan limits the amount of Rexulti provided to a 30 day supply.A physician reviewed your appeal and determined that the plan is not required to cover the Rexulti, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 20 milligram tablet prescribed for bipolar disorder (bipolar depression). 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. Your medical records show your doctor prescribed Latuda to treat your bipolar disorder with depression. 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 Latuda.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Morphine Sulfate ER 30 milligram tablets prescribed to take 2 tablets every 8 hours to treat low back and neck pain. The Part D plan denied your request stating Morphine Sulfate ER has quantity limitation of 60 milligrams to take 14 tablets in 7 days.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 condition. We also asked for medical records or other documentation to show why you need this amount of the medication. We did not receive the requested documentation.Your medical records show your doctor prescribed Morphine Sulfate ER 30 milligram tablets to take 2 tablets every 8 hours to treat low back and neck pain. However, your medical records do not support why an exception to the plans quantity limit is medically necessary.A physician reviewed your appeal and determined that the plan is not required to cover the Morphine Sulfate ER 30 milligram tablets prescribed to take 2 tablets every 8 hours, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Colchicine 0.6 milligram oral tablet prescribed daily for angioid streaks of macula. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Colchicine to treat your angioid streaks of macula. 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 Colchicine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lumigan 0.01% eye-drops prescribed for open angle glaucoma. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. Lumigan 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 a prior authorization request for Tymlos 3120 microgram/1.56 milliliter pen injector prescribed for postmenopausal osteoporosis. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies 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

You requested Cyclobenzaprine Hydrochloride 10 milligram tablets for muscle spasms related to musculoskeletal pain. 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 indicates your doctor prescribed muscle spasms related to chronic musculoskeletal pain. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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 Austedo 12 milligram tablets prescribed for chorea and hemi-ballism associated with hyperglycemic striatopathy. 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 indicates your doctor prescribed Austedo for chorea and hemi-ballism associated with hyperglycemic striatopathy. The medical records indicate the drug at issue was discussed to minimize parkinsonism and prevent future tardive dyskinesia. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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 5/325 milligram tablets prescribed for chronic pain. The Part D plan denied your request stating you were requesting a quantity exceeding the plan's limits. 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 submitted a statement to indicate the drug at issue was prescribed within the plan's quantity limits. The submitted documentation does not include medical records to support a prescribed diagnosis. A request for medical records was sent to your physician; 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 Entresto 49-51 milligram tablets prescribed twice daily for chronic systolic 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 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.Your medical records show your doctor prescribed Entresto to treat your chronic systolic congestive heart failure. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. At reconsideration, the physician changed the answer to a prior authorization question. However, the only physicians note provided is dated one year ago. Additional medical records and a prescriber statement were requested but we did not receive the requested documentation. 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 Entresto. 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 Mycophenolic Acid 360 milligram DR tablets prescribed for interstitial lung disease, not related to systemic sclerosis. 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 indicates your doctor prescribed Mycophenolic Acid for interstitial lung disease, not related to systemic sclerosis. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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 Januvia 100 milligram tablets prescribed for type II diabetes mellitus. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not adequately 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 Januvia 100 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 300 milligram capsules, 270 per 30 days to treat fibromyalgia. 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 plan limits the amount of Pregabalin to 450 milligrams per day. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vascepa 1 gram capsules prescribed to treat high triglyceride levels. 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 requested documentation.Your doctor prescribed Vascepa 1 gram capsules to treat high triglyceride levels. No medical records have been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia. A physician reviewed your appeal and determined that the plan is not required to cover Vascepa 1 gram capsules..
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 49-51 milligram tablet prescribed twice daily for nonischemic cardiomyopathy and chronic heart failure. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plans 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

You requested Ondansetron 4 milligram disintegrating tablets prescribed for nausea and vomiting secondary to ulcers following bariatric surgery. 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 indicates your doctor prescribed Ondansetron for nausea and vomiting secondary to ulcers following bariatric surgery. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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.