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

You requested Piqray 300 milligram daily dose tablets to treat metastatic papillary thyroid 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. The documentation shows the doctor prescribed Piqray to treat metastatic papillary thyroid cancer. The enrollee experienced disease progression on Sorafenib, Vemurafenib, and Lenvatinib. Molecular testing shows the enrollee has PIK3CA mutation. The physician states the enrollee has been treated with Piqray for the past year. However, the Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition. An oncologist reviewed your appeal and determined that the plan is not required to cover Piqray.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estring 2 milligram vaginal ring prescribed for vaginal atropy. 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 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, medical records were not received to 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 Estring.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine-Dextroamphetamine 10 milligram tablets prescribed for multiple sclerosis related fatigue. 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 Amphetamine-Dextroamphetamine for multiple sclerosis related fatigue. The Medicare approved compendia do not support the use of the drug at issue for your condition. As the drug was not prescribed for a medically accepted indication, payment cannot be made 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

At issue is a prior authorization request for Nuedexta 20-10 milligram capsules prescribed for pseudobulbar affect due to dementia. 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

At issue is Flector 1.3% Patch prescribed daily for myalgia, cervical disc degeneration, cervical radiculopathy, cervical spondylosis, lumbar spondylosis, and trochanteric bursitis. 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.The documentation shows the doctor prescribed Flector 1.3% Patch to treat the enrollees conditions. However, the Medicare approved compendia do not support the use of this drug for these conditions.A physician reviewed your appeal and determined that the plan is not required to cover Flector 1.3% Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidoderm 5% patch prescribed for polyneuropathy and chronic 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 Lidoderm patches for polyneuropathy and chronic pain. The Medicare approved compendia do not support the use of the drug at issue for your condition. As the drug was not prescribed for a medically accepted indication, payment cannot be made 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

At issue is Praluent 75 milligram/milliliter pen prescribed for mixed hyperlipidemia. 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. You may wish to submit a request to the plan to consider an off-formulary exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25-microgram Inhaler to treat chronic obstructive pulmonary disease. 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 has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug. 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 Loteprednol Etabonate 0.5% gel prescribed for ocular pain, trigeminal neuralgia, and keratitis. 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 Loteprednol Etabonate gel for ocular pain, trigeminal neuralgia, and keratitis. 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 a request for coverage of Droxidopa 300 milligram capsules. 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 Droxidopa has been prescribed for symptomatic orthostatic hypotension, not caused by primary autonomic failure, dopamine -hydroxylase deficiency, or nondiabetic autonomic neuropathy. 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 Droxidopa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dalfampridine ER 10 milligram ER 12 hour tablets to treat nystagmus and weakness to the lower extremities. 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 Dalfampridine ER 10 milligrams ER 12 hour tablet to treat nystagmus and weakness to the lower extremities. 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 Dalfampridine ER 10 milligram ER 12 hour tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Aptiom 400 milligram tablets prescribed to treat trigeminal neuralgia. 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 Aptiom 400 milligram tablets to treat trigeminal neuralgia. 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 Aptiom 400 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 20-10 milligram capsules prescribed as directed for pseudobulbar affect associated with Alzheimers disease. 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 the doctor prescribed Nuedexta for the treatment of for pseudobulbar affect associated with Alzheimers disease. The 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 Nuedexta. 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 Lidocaine PF 10 milligram/milliliter prescribed for pain being administered as an injection in the prescribers office.  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.Drugs furnished Incident To a physicians service are excluded from Medicare Part D coverage.  Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets prescribed for atrial fibrillation. 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. Eliquis 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

You requested Privigen 10 gram/100 milliliter solution prescribed for use with an infusion pump for the treatment of primary 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. The record shows Privigen is being administered to the enrollee 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 DME, 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 Privigen. 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 Buprenorphine 5 micrograms/hour transdermal patches prescribed as directed for chronic 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 records submitted at the reconsideration level. The medical records show the provider prescribed Buprenorphine to treat chronic pain of the knees and low back. The 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 Buprenorphine. 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 a formulary exception request for Stelera 45 milligram/0.5 milliliter injection prescribed for psoriasis vulgaris. 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. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Stelera.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Oxycontin ER 10 milligram extended release tablets prescribed for chronic pain syndrome, low back pain, and cervicalgia. The Part D plan denied the request. We received the case to perform an independent and de novo review. 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 Part D plan has prior authorization requirements that must be satisfied before Oxycontin ER will be covered. The submitted documentation does not sufficiently address the plans requirements. During this review, a prescriber statement and supporting medical records were requested from the prescriber to fully address the plans coverage requirements. However, the prescriber did not respond to our request.Therefore, there is insufficient documentation to determine if the plans prior authorization requirements have been met for this medication. A physician reviewed the appeal and determined that the plan is not required to cover the Oxycontin ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kisqali 600 milligram daily dose tablets prescribed for metastatic, hormone receptor positive, human epidermal growth factor receptor-2 negative breast 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 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 medical records show you prescribed Kisqali 600 milligrams to treat the enrollees metastatic, hormone receptor positive, human epidermal growth factor receptor-2 negative breast cancer. The 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.An oncologist reviewed your appeal and determined that the plan is not required to cover Kisqali 600 milligram daily dose tablets. 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 Actemra 400 milligrams per 20 milliliters solution to treat birdshot chorioretinopathy. 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 Actemra 400 milligrams per 20 milliliters solution to treat birdshot chorioretinopathy. However, the Medicare approved compendia do not support the use of this drug for your conditions.A physician reviewed your appeal and determined that the plan is not required to cover Actemra 400 milligrams per 20 milliliters solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Entresto 49-51 milligram tablets prescribed twice daily.  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 available.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 did not receive the documentation requested.The documentation provided does not include medical records to establish the enrollees diagnosis. It could not be determined whether the requested drug was being prescribed for 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 Entresto.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clobetasol 0.05% ointment to treat lichen sclerosus. 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 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 Clobetasol 0.05% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ruxience 10 milligram/milliliter vial prescribed for stiff-person syndrome and chronic pain syndrome. 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 Ruxience for stiff-person syndrome and chronic pain syndrome. The Medicare approved compendia do not support the use of the biologic at issue for your conditions. As it cannot be determined that the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch to treat bilateral shoulder 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.The documentation shows your doctor prescribed Lidocaine 5% patch to treat bilateral shoulder pain. 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 Lidocaine 5% patch.