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

At issue is Pentasa 500-milligram Extended Release Capsule. At initial determination and redetermination the diagnoses of other specified signs and symptoms involving the digestive system and abdominal and ileostomy status were given. 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.At reconsideration a diagnosis of enteritis was given. The use of the requested drug to treat the provided diagnoses are off-label uses. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. 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 Fasenra 30 milligram per milliliter syringe prescribed to treat eosinophilic asthma. 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 Fasenra 30 milligram per milliliter syringe to treat eosinophilic asthma. 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 Fasenra 30 milligram per milliliter syringe, as the prior authorization criteria was not satisfied. 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 Zolpidem Tartrate 5 milligram tablet prescribed for insomnia. 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 for 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 you prescribed Zolpidem Tartrate 5 milligram tablet to treat insomnia. 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 Zolpidem Tartrate 5 milligram tablet. 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 prescribed Enbrel Sureclick 50 milligram per milliliter. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.Your medical records show your doctor prescribed Enbrel Sureclick to treat your moderate to severe rheumatoid arthritis. 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 Enbrel Sureclick. 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 Benlysta 200 milligram per milliliters auto-injector syringe prescribed to treat systemic lupus erythematosus. 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.Benlysta is included on Tier 5 of the plans formulary. This Tier is identified as a Specialty Tier. The plan is not required to grant a tier exception for drugs available on their Specialty Tier. Therefore, a tier exception cannot be considered.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 Mayzent 0.25-milligram Starter Pack to treat progressive multiple sclerosis. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan 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 formulary 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 Humalog 100-units/milliliter. The case was auto-forwarded by the plan. 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. We also researched Medicare systems and reviewed the enrollment data available.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 Pentasa 500 milligram capsules prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is included on Tier 4 of the plans formulary. This Tier is identified as a Specialty Tier. The plan is not required to grant a tier exception for drugs available on their Specialty Tier. Therefore, a tier exception cannot be considered.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 Lumigan 0.01 percent solution prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. 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

You requested prior authorization for Megestrol Acetate 400 milligram/10 milliliter prescribed as directed for poor appetite and weight loss related to esophageal tumor arising from Barrett's esophagitis. The case was auto-forwarded by the plan.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 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 Sildenafil 20 milligram tablets to treat erectile dysfunction. 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.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 Entresto 24 milligram-26 milligram tablets prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Entresto 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 Diclofenac Sodium 3% gel prescribed for osteoarthritis. 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 Diclofenac Sodium gel for osteoarthritis. 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 Ondansetron Hydrochloride 4 milligram tablets. The Part D plan denied the request for coverage because the medication was being used for a non-medically accepted indication. Additionally, to approve coverage under Part D, the requested drug must not be a full replacement for intravenous antiemetic within 48 hours of cancer treatment. 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 does not indicate that the Ondansetron Hydrochloride is being used for nausea caused by cancer treatment. Therefore, the plans denial reason regarding cancer treatment is not applicable to this case. The documentation originally submitted to the plan indicates that Ondansetron Hydrochloride was prescribed to treat nausea due to chronic migraines. However, the Medicare approved compendia do not contain any citations to support the use of Ondansetron Hydrochloride for the treatment of this condition.At reconsideration, the prescriber has stated that Ondansetron Hydrochloride is being prescribed for gastritis and nausea due to medication use. However, the prescriber has failed to state what medication is causing the enrollees nausea. Furthermore, no medical records have been submitted to validate the change in diagnoses. Therefore, there is insufficient documentation to determine if the Ondansetron Hydrochloride is being prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the plan is not required to cover the Ondansetron Hydrochloride.
Appeal type: Prescription Drug
Decision: Favorable

You requested Otezla 30 milligram oral tablet prescribed twice daily for psoriasis. The Part D plan denied the request because it does not meet the plans criteria, that drug was prescribed by a dermatologist.. We received a reconsideration 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. We also researched Medicare regulations and Medicare approved compendia.At reconsideration Otezla 30 milligram oral tablet prescribed twice daily for psoriasis vulgaris, per prescriber statement. This is an FDA approved diagnosis. The drug is being prescribed by a dermatologist office. Additionally, a citation in DrugDex, a Medicare approved compendium, supports the use of the requested drug for the condition indicated:  In two 16-week, randomized trials in patients with moderate to severe psoriasis, apremilast compared with placebo significantly increased the proportion of patients achieving a 75% or greater reduction from baseline in Psoriasis Area and Severity Index Score. Therefore, it is considered a medically accepted indication.The plan has prior authorization criteria for approval of this drug. The documentation provided satisfies the plans coverage criteria. This patient has tried and failed a prior biologic agent for the condition. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ure-Na packet for hyponatremia. 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.According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to reimburse you for the Ure-Na.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 112 microgram tablets prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Synthroid 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 Ondansetron Hydrochloride 4 milligram tablet prescribed for nausea. 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 Ondansetron Hydrochloride to treat your nausea. 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 Ondansetron Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Morphine Sulfate ER 15 milligram tablet. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation 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. However, we did not receive the documentation requested. Payment cannot be allowed without additional documentation because the records submitted do not support a medically accepted indication. It is noted that this medication has prior authorization criteria that must be met if a medically accepted indication is established.A physician reviewed your appeal and determined that the plan is not required to cover Morphine Sulfate ER 15 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sprycel 70 milligram tablets prescribed twice daily for metastatic osteosarcoma. 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 Sprycel to treat metastatic osteosarcoma. 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 Sprycel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Procrit 4000 units/milliliter prescribed as needed for anemia, unspecified. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The documentation shows your doctor prescribed Procrit to treat your anemia, unspecified. 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 Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 30 milligram tablet prescribed for attention deficit hyperactivity disorder. 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, 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 Vyvanse 30 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine Hydrochloride 2 milligram sublingual tablet prescribed daily for chronic neck 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 Buprenorphine Hydrochloride to treat your chronic neck 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 Buprenorphine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24-milligram-26-milligram tablet to treat congestive heart failure and non-ischemic cardiomayopathy. 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.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 indication. 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 a request for coverage of Corlanor 5 milligram tablets. The Part D plan denied the request because the plans prior authorization requirements were not satisfied. 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 Corlanor has been prescribed for treatment of postural orthostatic tachycardia syndrome. 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. Since the drug is not eligible for coverage under Medicare Part D, the plans prior authorization requirements will not be addressed. A physician reviewed your appeal and determined that the plan is not required to cover the Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Plegridy 125 microgram per 0.5 milliliter subcutaneous injection pen that has been prescribed for relapsing-remitting multiple sclerosis. 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 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.Plegridy 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 enrollees 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.