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

At issue is a request for coverage of Ozempic 2 milligram per 1.5 milliliter subcutaneous injection pen. 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 Ozempic has been prescribed for prediabetes and weight loss. 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. Furthermore, it should be noted that drugs prescribed for weight management are excluded from Part D coverage. A physician reviewed the appeal and determined that the plan is not required to cover Ozempic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trihexyphenidyl HCL 2 milligram tablets prescribed to treat schizoaffective disorder, depressive type and extrapyramidal disease resulting from the use of atypical antipsychotics. 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 Part D plan denied your request stating that the provided diagnoses were non-medically accepted indications. The Medicare approved compendia indicates the diagnosis of extrapyramidal disease is a medically accepted indication. However, Trihexyphenidyl HCL is not on your 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 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 Trihexyphenidyl HCL 2 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine Hydrochloride tablet sublingual 2 milligram prescribed 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 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 received the documentation and included it in our review.The documentation shows your doctor prescribed Buprenorphine Hydrochloride tablet(s) sublingual to treat your chronic pain. However, the Medicare approved compendia do not support the use of this specific drug in tablet form for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride tablet(s).
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Levothyroxine 25 microgram tablets prescribed for unknown diagnosis. The Part D plan did not make a 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 you purchased Levothyroxine for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed twice daily for rib fractures and contusions. 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 your rib fractures and contusions. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

Diclofenac Sodium 1 percent gel prescribed as directed for left knee pain without history of osteoarthritis.  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.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, as ordered, is not being used for a medically accepted indication. The requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mayzent 2 milligram tablet prescribed for 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need the medication. We received the documentation and included it in our review.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 Mayzent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Insulin Aspart 100 units/milliliter pen prescribed as directed for Type 2 diabetes mellitus. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.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. A physician reviewed your appeal and determined that the plan is not required to cover Insulin Aspart.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lansoprazole delayed-release 30 milligram capsules prescribed to take 1 capsule, by mouth, once daily before a meal to treat gastroesophageal reflux 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 prescriber indicates that a couple of the plans alternative formulary drugs were tried and failed or could cause harm. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the records do not support why all 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 Lansoprazole delayed-release 30 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Erythromycin 250 milligram oral tablet prescribed for gastroparesis unspecified. 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 Erythromycin to treat your gastroparesis. 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 Erythromycin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin Extended Release 30-milligram tablet to treat pain related to cancer, multiple sites. 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

You requested Armodafinil 250 milligram oral tablet prescribed for unspecified hypersomnia. 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 Armodafinil to treat your unspecified hypersomnia. 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 Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sunosi 75 milligram oral tablet prescribed for excessive daytime sleepiness not due to narcolepsy or obstructive sleep apnea. 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 medical records show Sunosi was prescribed to treat excessive daytime sleepiness. The medical records also show a sleep study was performed, which showed no evidence of sleep disordered breathing. 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 Sunosi.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Linzess 72 microgram capsules prescribed for constipation. The Part D plan denied the 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 records submitted at the reconsideration level. Linzess 72 microgram capsules were prescribed to treat constipation. The drug is not on the plans formulary. The medical records and prescribers statement do not support you could not tolerate all of the alternate medications 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. A physician reviewed your appeal and determined that the plan is not required to cover Linzess.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myorisan 40 milligram capsules prescribed for adult acne of the face. The Part D plan denied your 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.In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, additional information was required from the prescriber. A request was submitted to the prescriber to provide a diagnosis, to clarify the medical history, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.   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

At issue is Albuterol Sulfate 0.083% Nebulization Inhalation. 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: Favorable

At issue is Dextroamphetamine Sulfate extended release 15 milligram capsule prescribed twice daily for narcolepsy. 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 medical records show the physician prescribed Dextroamphetamine Sulfate to treat your narcolepsy. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of the requested drug for your condition: Dextroamphetamine is indicated for the treatment of narcolepsy.The prescriber states that you have also tried and failed or had adverse effects with Modafinil and Adderall.  A physician reviewed your appeal and determined that an exception can be granted to cover the drug that is not on your plans formulary. Therefore, the plan is required to cover Dextroamphetamine Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine 10 milligram tablets prescribed as directed for fibromyalgia. 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.Your medical records show your doctor prescribed Cyclobenzaprine to treat your fibromyalgia. 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 Cyclobenzaprine.
Appeal type: Prescription Drug
Decision: Favorable

You requested Cequa 0.09% solution. 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 Cequa to treat your keratoconjunctivitis sicca (dry eye syndrome). DrugDex, a Medicare approved compendium, supports the use of this drug for your condition. The medical records also show that you tried and failed Restasis.A physician reviewed your appeal and determined that the plan is required to cover Cequa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rytary 48.75 milligram/195 milligram controlled release capsules prescribed for Parkinsons disease. 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. Rytary is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexium Delayed Release 40-milligram capsule to treat gastroesophageal reflux disease. 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 Zenpep DR 40-126-168 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. Zenpep is a biological product drug on Tier 3 of the plans formulary. There are no biological product drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Octagam 10% intravenous solution. 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 Octagam 10% solution has been prescribed for chronic inflammatory demyelinating polyneuropathy. However, the Medicare approved compendia do not contain any citations to support the use of the brand drug, Octogam 10% for the treatment of chronic inflammatory demyelinating polyneuropathy. 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 the appeal and determined that the plan is not required to cover the Octagam 10% solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methocarbamol 500 milligram oral tablet prescribed daily 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 information submitted at the reconsideration level. The documentation shows your doctor prescribed Methocarbamol to treat your muscle spasms and chronic pain syndrome. 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 Methocarbamol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 20-10 milligram capsules prescribed daily for pseudobulbar affect. 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 Nuedexta to treat your pseudobulbar affect. 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 Nuedexta. The documentation does not satisfy the plans coverage criteria because a diagnosis of amyotrophic lateral sclerosis or multiple sclerosis is not documented.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 tiering exception request for Advair Diskus 100-50 micrograms/dose Aerosol Powder Breath Activated to treat an unknown condition of the enrollee. 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.Advair Diskus 100-50 micrograms/dose Aerosol Powder Breath Activated is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.