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

You requested Humira (CF) 40 milligram/0.4 milliliter Syringe Kit prescribed for systemic sarcoidosis with cardiac involvement, and seronegative rheumatoid arthritis. 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 Humira to treat your rheumatoid arthritis. The following citation was referenced in the American Hospital Formulary Service Drug Information, a Medicare approved compendium, and supports the use of this drug for your condition: Humira is used for the management of the signs and symptoms of rheumatoid arthritis, to induce a major clinical response, to improve physical function, and to inhibit progression of structural damage associated with the disease in adults with moderate to severe active rheumatoid arthritis. Humiria can be used alone or in combination with methotrexate or other nonbiologic disease-modifying antirheumatic drugs.The documentation also supports previous therapies including Azathioprine, Prednisone, and Methotrexate. A physician reviewed your appeal and determined that the plan is required to cover Humiria. The medical records support a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus 100 unit/milliliter solution prescribed for the enrollees condition. 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.Lantus is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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 Loteprednol Etabonate 0.5% DRP to treat dry eye syndrome.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 Loteprednol Etabonate 0.5% DRP.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Novolog Flexpen 100 milliliter insulin pen. 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 condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.There was no diagnosis given at initial determination or at redetermination. No medical records were submitted to support the requested drug was prescribed to treat a medically accepted indication. 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 Novolog Flexpen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Topiramate 25 milligram tablet prescribed twice daily for new daily persistent headache. 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 Topiramate to treat your new daily persistent headache. 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 Topiramate.
Appeal type: Prescription Drug
Decision: Favorable

At issue is prescribed Xgeva 70 milligrams/milliliter injection prescribed for bone metastasis associated with 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 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 received the documentation and included it in our review.Your medical records show your doctor prescribed Xgeva  for bone metastasis associated with prostate cancer. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The medical records include documented bone metastasis. Therefore, the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Xgeva. The physician reviewer also determined that an exception to the plans prior authorization requirements can be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Icosapent Ethyl 1 gram capsules prescribed as directed for mixed hyperlipidemia. 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 the doctor prescribed Icosapent Ethyl to treat mixed hyperlipidemia. However, the 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 Icosapent Ethyl.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Vascepa 1 gram capsules. 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. The documentation indicates that Vascepa has been prescribed for mixed hyperlipidemia. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Myrbetriq 25 milligram prescribe for an overactive bladder. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. We also researched Medicare regulations and reviewed the enrollment data available. We requested addition information from the prescriber but did not receive a response. The information was insufficient to make a decision on your appeal. A physician reviewed your appeal and determined that the plan is not required to cover Myrbetriq.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Hydroxyzine Hydrochloride 50 milligram tablets prescribed for anxiety. 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.Your medical records show your doctor prescribed Hydroxyzine Hydrochloride to treat your anxiety. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Your doctor indicates that you have been on this drug since 2018 and have been doing well on it. You tried and failed Buspirone, Escitalopram and several other drugs and your doctor indicates a negative outcome will occur if you continue to go without this medication. The documentation provided does show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Hydroxyzine Hydrochloride.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mycophenolate 500 milligram tablets prescribed for kidney transplant rejection. 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.Medicare systems show that your kidney transplant was not completed while covered under Medicare Part A/B. The drug is eligible for Part D coverage.A physician reviewed your appeal and determined that the plan is required to cover Mycophenolate.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tacrolimus 1 milligram capsules prescribed for kidney transplant rejection. 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.Medicare systems show that your kidney transplant was not completed while covered under Medicare Part A/B.Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Tacrolimus and Mycophendate are being use together for renal transplant rejection. The documentation provided shows the requirements were met as the enrollee is also taking Mycophendate along with Tacrolimus.A physician reviewed your appeal and determined that the plan is required to cover Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydroxyzine Hydrochloride 25 milligram tablets. 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.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 cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate Hydrochloride 10 milligram tablets prescribed for fatigue related to multiple sclerosis. 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 Methylphenidate Hydrochloride to treat your fatigue related to multiple sclerosis. 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 Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sunosi 75 milligram tablets prescribed to treat hypersomnolence in an enrollee with obstructive sleep apnea on CPAP. 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. We also researched Medicare regulations and reviewed the enrollment data available. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plan requires the sleep study test be submitted and documentation of an adequate trial and failure of both Modafinil and Armodafinil. The medical records do not include the required documentation. Therefore, the prior authorization requirements were not satisfied.A physician reviewed your appeal and determined that the plan is not required to cover Sunosi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 3 milligram capsules prescribed for unspecified chronic diarrhea, small intestinal bacterial overgrowth, and common variable immune deficiency. 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 prescriber indicated that Budesonide was prescribed for unspecified chronic diarrhea, small intestinal bacterial overgrowth, and common variable immune deficientcy. 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 Budesonide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trazodone Hydrochloride 150 milligrams.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. The documentation is insufficient to determine if the drug requested is prescribed for a medically accepted indication. There was insufficient information provided to make a decision. A physician reviewed your appeal and determined that the plan is not required to cover Trazodone Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 50 milligram tablets prescribed for the enrollees condition. 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 ER is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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: Favorable

At issue is Lubiprostone 24 microgram capsule prescribed twice daily for chronic idiopathic constipation. 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 show the doctor prescribed Lubiprostone to treat the enrollees chronic idiopathic constipation. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The medical record states the enrollee had  flatulence/intolerance with a trial of Lactulose and Linzess was not effective. The documentation provided does show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Lubiprostone. The physician reviewer also determined that the plans prior authorization requirements have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 8-milligram tablet sublingual to treat chronic pain syndrome. 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.At reconsideration a diagnosis of opioid dependence, unspecified was given. The medical records provided by the prescriber did not support the use of Buprenorphine for this diagnosis. The use of the requested drug to treat the provided chronic pain syndrome 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

At issue is Benztropine Mesylate 0.5-milligram tablet to treat Parkinson's disease associated tremors. 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/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 Dronabinol 2.5-milligram tablet to treat abnormal weight loss. 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 Moxifloxacin Hydrochloride 0.5% ophthalmic solution prescribed for nail deformity. 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 Moxifloxacin Hydrochloride to treat your nail deformity/other nail disorders. However, the Medicare approved compendia do not support the use of this specific drug for your condition(s). A physician reviewed your appeal and determined that the plan is not required to cover Moxifloxacin Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine 5% ointment. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Lidocaine 5% ointment has been prescribed for osteoarthritis, low back pain, and left-sided sciatica. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Buprenorphine 10-micrograms/hour to treat severe pain, spondylosis without myelopathy or radiculopathy of lumbar region and sciatic of the right side. The Part D plan denied the request. We received an expedited 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.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.Our physician reviewer's opinion is that non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium Gel 1% prescribed for back, neck, and knee pain. 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 indicate you have low back pain, lumbar stenosis, chronic neck pain post laminectomy, cervical radicular pain, bilateral carpal tummel, and knee pain post knee arthroplasty. You were prescribed Diclofenac Sodium Gel 1 %. 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 Diclofenac Sodium Gel 1%.