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

At issue is Repatha Pushtronex System 420 milligrams per 3.5 milliliter solution cartridge prescribed every month for familial hypercholesterolemia. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Repatha Pushtronex System.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Sildenafil Citrate tablets of an unknown strength prescribed for an unknown condition. 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. The documentation does not include any medical records from the prescribing physician. A request was submitted to the prescriber to provide a diagnosis and 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 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 Lidocaine and Prilocaine 2.5%-2.5% cream prescribed for malignant neoplasm of the pancreas. 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. The documentation shows your doctor prescribed Lidocaine and Prilocaine to treat malignant neoplasm of the pancreas However, the Medicare approved compendia do not support the use of this drug for your condition. Medical records documenting use for a medically accepted indication were not submitted. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine and Prilocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig 140-milligrams/milliliter Solution Auto-Inject subcutaneous to treat migraine without status migrainosus, not intractable, unspecified migraine type (G43.909). 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.A diagnosis of chronic migraine without aura, intractable, without status migrainosus was given on the prior authorization (G43.719). However, the documentation does not satisfy the plans coverage criteria.  The medical record provided does not address the plan's 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 Cosentyx 150 milligram/milliliter Pen Injector prescribed for hidradenitis suppurativa. 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. The documentation shows you were prescribed Cosentyx Pen Injector to treat your hidradenitis suppurativa. 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 Cosentyx.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Bosentan 62.5 milligram tablets prescribed for pulmonary arterial 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 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.Bosentan is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan would likely not be as effective as the requested drug for the noted condition and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuedexta. At initial determination and redetermination the diagnoses of cerebral infarction and cerebral vascular accident with involvement of left side of body were given. The Part D plan denied the request stating that the provided diagnoses are non-medically accepted indications.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 diagnoses of other paralytic syndrome following cerebral infarction affecting unspecified side and atherosclerotic heart disease of native coronary artery without angina pectoris were given. No medical records were provided by the prescriber to support these diagnoses. It could not be determined whether the requested drug was being prescribed for a medically accepted indications. 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 Budesonide 3 milligram capsules prescribed initially for irritable bowel syndrome with diarrhea. 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 documentation provided does not show the enrollee has satisfied the plan's coverage criteria. There was no supporting evidence of mild to moderate active Crohns disease as required by the plan for coverage of the drug.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

You requested Xpovio 20 milligram tablet therapy pack prescribed for metastatic melanoma with positive tyrosine-protein kinase 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 Xpovio 20 milligram tablet therapy pack to treat the enrollees metastatic melanoma. However, the Medicare approved compendia do not support the use of this drug for this condition.  There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal.A physician reviewed your appeal and determined that the plan is not required to cover Xpovio 20 milligram tablet therapy pack.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tadalafil 20 milligram oral tablet. 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 redetermination. In addition, no medical records were provided. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication approved by the Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Mobic 7.5 milligram tablets prescribed for erosive arthritis. 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.Mobic is not included in the plans formulary. The doctor who prescribed your medication has not provided patient specific clinical rationale, supported by medical records, as to why the drugs that are included in the plans formulary to treat your condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Timolol Maleate Gel Forming Solution 0.5% prescribed for bilateral open-angle glaucoma.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. Timolol Maleate Gel Forming Solution is a brand drug on Tier 4 of the plans formulary. Your doctor indicated that a lower tier formulary alternative would be as effective as the requested drug. 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 Xifaxan 550 milligram oral tablet prescribed three time daily for small intestinal bacterial overgrowth. 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 Xifaxan to treat your small intestinal bacterial growth. However, 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nyamyc 100,000 units/gram powder for the enrollees condition. 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. 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 Nyamyc.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hizentra 4 gram/20 milliliter vial prescribed for use with an infusion pump for the treatment of common variable immunodeficiency. 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 record shows Hizentra is being administered to the enrollee subcutaneously through an external infusion pump used in the home. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment, if the equipment used in the patients home. Payment may be made for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. The Medicare policy supports the enrollees diagnosis is eligible for coverage under Medicare Part B. We determined that the Medicare Part D plan is not required to cover Hizentra. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Methylphenidate ER 36 milligram tablets. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The medical records submitted at reconsideration indicate that Methylphenidate ER is being prescribed for the treatment of narcolepsy. However, Methylphenidate ER is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the noted condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Colesevelam 625 milligram tablets prescribed for irritable bowel syndrome with diarrhea. 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. The documentation shows you were prescribed Colesevelam 625 milligram tablets to treat irritable bowel syndrome with diarrhea. 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 Colesevelam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla Starter Pack 10-20-30 milligrams prescribed for psoriatic 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 prescriber indicated that the diagnosis is psoriatic arthritis with spine involvement. The records support the drug is medically indicated for the provided diagnosis. However, the 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 medical records do not support why all the plans alternative 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 Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Memantine 10 milligram tablet to treat Lewy Body dementia.  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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sildenafil Citrate 50 milligram tablets. 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 Sildenafil Citrate has been prescribed for the management of benign prostatic hyperplasia with lower urinary tract symptoms. 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 Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta 50 milligram tablets. 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 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. We submitted a request for information to your prescriber and did not receive the information requested. Your prescriber submitted office notes that show you have allergies to multiple medications. However, the physician office note submitted does not indicate what the drug at issue is being prescribed for and there was no mention in the note of the drug. The plan's step therapy criteriahave not been satisfied.A physician reviewed your appeal and determined that the plan is not required to cover Nucynta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cosopt Eye Drops 22.3 milligram-6.8 milligram/milliliter prescribed for open angle glaucoma. 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 Dorzolamide/Timolol Ophthalmic Drops had been tried without adequate response. However, all formulary alternative drugs were not addressed. 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 Cosopt Eye Drops.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Strattera 40 milligram capsules 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. This drug is not included on your plans formulary. Per Medicare rules, non-formulary drugs are 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 Sucraid Solution 8500 unit/milliliter prescribed for sucrose-isomaltase 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 Sucraid prescribed due to the diagnosis is sucrose-isomaltase deficiency.agnosis. However, the Medicare approved compendia do not support the use of this drug for your condition as it is not noted to be congenital. A physician reviewed your appeal and determined that the plan is not required to cover Sucraid.