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

You requested Epidiolex 100 milligram/milliliter solution prescribed 4.4 milliliter by mouth twice a day for partial idiopathic epilepsy with seizures of localized onset, intractable, without status epilepticus. 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 Epidiolex to treat your epilepsy. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Adjunctive cannabidiol significantly decreased seizure frequency at week 12 and the improvement was stable over 48 weeks in two open-label studies of treatment-resistant epilepsy in children and adults. The medical records support you are also taking Lamotrigine and Briviact. Therefore, Epidiolex is being used as an adjunct medication for your epilepsy.A physician reviewed your appeal and determined that the plan is required to cover Epidiolex. .
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Adderall XR 25 milligram capsule prescribed as directed for sleep apnea related 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 Adderall XR to treat your sleep apnea related 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 Adderall XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 10 milligram capsule prescribed daily for nausea and vomiting, opioid dependence, and chronic pain syndrome. The Part D plan did not make a decision. 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 Dronabinol to treat the enrollees nausea and vomiting, opioid dependence, and chronic pain syndrome. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed the appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed as directed for spondylosis without myelopathy or radiculopathy, lumbar region. 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 Cyclobenzaprine Hydrochloride to treat your spondylosis without myelopathy or radiculopathy, lumbar region. 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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Fluocinonide 0.05% topical cream prescribed for Darier's disease. 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. Fluocinonide cream 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Magnesium Gluconate 500 milligram tablet prescribed six times daily for magnesium deficiency. The Part D plan denied the request. We performed and 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 determined that the plan is not required to cover Magnesium Gluconate because it it is a prescription vitamin and mineral product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulicity 1.5 milligram/0.5 milliliter pen injector 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. Trulicity 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 Pradaxa 150 milligram capsules prescribed to treat traumatic subdural hemorrhage with transverse sinus thrombosis. 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 Pradaxa 150 milligram capsules to treat traumatic subdural hemorrhage with transverse sinus thrombosis. 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 Pradaxa 150 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 20 milligram tablets prescribed for the enrollees condition. 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.Xarelto 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 Xeljanz 10 milligram tablets prescribed twice daily for alopecia areata. 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 doctor prescribed Xeljanz to treat alopecia areata. The prescriber statement provides an additional diagnosis of alopecia universalis. 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 Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Procardia XL 90 milligram tablet prescribed for hypertension. 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, medical records were not provided. 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 Procardia XL.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for pain from infected hardware in knee replacement. 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 did not contain medical records or a supporting statement. A request for information was sent to the prescriber. The prescriber submitted a supporting statement; however, no medical records were submitted for review. 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 Metolazone 5 milligram oral tablet prescribed daily for congestive heart failure with associated edema. 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 Metolazone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Xolair 150 milligram/milliliter injection prescribed for idiopathic urticaria. 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 biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Gabapentin 800 milligram tablets, 2 tablets three times daily (4800 milligrams total per day).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 Gabapentin 800 milligram tablets, 180 tablets per 30 days, has been prescribed for the treatment of chronic midline low back pain with right-sided sciatica and postherpetic neuralgia. The plan limits the amount of Gabapentin 800 milligram tablet to 120 tablets per 30 days. However, as noted in the Medicare compendium, American Hospital Formulary Service Drug Information (AHFS-DI), In clinical studies evaluating Gabapentin for the treatment of postherpetic neuralgia, dosages of the drug ranging from 1.8 to 3.6 grams (1800 to 3600 milligrams) daily were effective, but there was no evidence that dosages exceeding 1.8 grams (1800 milligrams) daily provided any additional benefit.' The dose being requested by the prescriber is 4.8 grams (4800 milligrams) daily, which exceeds the maximum dose outlined in the Medicare approved compendium.   Therefore, an exception to the plans coverage criteria is not supported.  Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 10 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. Xarelto 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 Pennsaid 20 milligram per gram 2% pump prescribed daily for osteoarthritis of the knees. 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. 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.At initial determination the documentation shows your doctor prescribed Pennsaid to treat your osteoarthritis of the knees. However, no medical records have been submitted to support this condition. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia. As such, 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 Pennsaid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Tadalafil 5 milligram tablets to treat benign localized prostatic hyperplasia with lower urinary tract symptoms and erectile dysfunction. 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 Prior Authorization request form submitted and signed by the prescriber dated 5/5/2021 sates, 'Take one tablet daily as needed.'  Note that 'as needed dosing' is consistent with the treatment of erectile dysfunction and not Benign prostatic hyperplasia.  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 Viagra 100 milligram tablets to treat erectile dysfunction. 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.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

You requested Adderall XR 20 milligram capsules prescribed for idiopathic hypersomnia. 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 Adderall XR for idiopathic hypersomnia. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As the drug was not 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 Horizant 600 milligram extended-release oral tablet prescribed daily for restless leg syndrome. 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. 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 Horizant.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Viibryd 40 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. Viibryd 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: Favorable

At issue is a request for coverage of Prolia 60 milligram per milliliter subcutaneous injection syringe.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. During this review, a prescriber statement and supporting medical records were requested from the prescriber. The prescriber responded and submitted the requested documentation.The Part D plans requirements for coverage of Prolia is to ensure that the medication is being used for a medically accepted indication, to establish that the medication is available for coverage under Medicare Part D rather than Medicare Part B, and to ensure that the requested amount of the drug does not exceed the plans quantity limit of 1 injection syringe per 180 days. The amount of drug being requested from the prescriber is 1 injection syringe per 180 days. Therefore, the requested amount of drug does not exceed the plans quantity limits. The submitted medical records indicate that Prolia has been prescribed for the treatment of postmenopausal osteoporosis with a high risk of fracture. The medical records show that the enrollee has a high risk of fracture due to having a low body mass index and a history of a fracture of the right third phalanx in 2017. The records also show that the enrollee previously took alendronate from 2015 to 2018 to manage the osteoporosis. The enrollees latest dual-energy X-ray absorptiometry (DEXA) scan obtained on June 10, 2019, confirms the presence of osteoporosis with a lumbar spine T-score of -3.0. The use of Prolia for the treatment of postmenopausal osteoporosis with a high risk of fracture is a medically accepted indication as outlined in the Medicare approved compendia.For an injectable osteoporosis drug to be available for coverage under Medicare Part D, the enrollee must not be receiving Medicare home health benefits, the medication must be purchased directly from the pharmacy, and the drug must be administered either by the enrollee or by their physician. The prescriber has indicated that the enrollee is not receiving home health services, the drug is being purchased directly from the pharmacy, and that the enrollee self-administers the injection.  To summarize, the documentation supports that the medication is being used for a medically accepted indication, the drug is eligible for coverage under Part D, and the quantity limit has not been exceeded. Therefore, coverage for the drug can be allowed. A physician reviewed the appeal and determined that the plan is required to cover the Prolia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prior authorization for Dronabinol 5 milligram capsules prescribed as directed for anorexia, unspecified severe protein-calorie malnutrition, Covid 19 and failure to thrive. 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 Dronabinol to treat your anorexia, unspecified severe protein-calorie malnutrition, Covid 19 and failure to thrive. 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 Dronabinol.