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

At issue is Hysingla Extended Release 30-milligram tablet. 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.A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records. A reply from the prescriber was not received. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xiirda 5% eye drops prescribed daily for dry eye 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. 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.. At initial determination the diagnosis of dry eye syndrome was given. However, no medical records have been submitted for review. 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 formulary exception was not addressed because 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 Xiirda.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benicar 40 milligram tablet. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. We asked your prescriber to provide a diagnosis and 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.Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.  A physician reviewed your appeal and determined that the plan is not required to cover the requested drug. Your request for a formulary exception was not reviewed. We cannot consider a formulary exception for a drug for which the Medicare Part D plan is unable to provide coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Baclofen 10 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.Baclofen is a generic drug on Tier 3 of the plans formulary. A supporting statement and medical records were requested from your doctor; however, no further documentation was received. The documentation on hand does not address why all alternative lower-tier medication on the plans formulary would not work for you. All drugs on lower tiers have not been tried. 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 Methotrexate 2.5 milligram tablets prescribed for seronegative rheumatoid arthritis.   The request was auto-forwarded.  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 satisfies the plans coverage criteria.  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 NP Thyroid 90 milligram tablets prescribed for thyroid cancer. 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 drug at issue is not Food and Drug Administration approved. 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

You requested coverage for Synvisc-One 48 milligram per 6 milliliter prefilled syringe prescribed for osteoarthritis of the right knee. The Part D plan your 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.Synvisc-One has been classified by the Food and Drug Administration as a medical device. As such, it does not meet the definition of a Part D drug. Therefore, the Synvisc-One is not eligible for coverage under Medicare Part D. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Acetylcysteine 10% ophthalmic 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 Acetylcysteine ophthalmic solution has been prescribed for filamentary keratitis of the left eye. 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 the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Carisoprodol 350 milligram tablets. 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 does not contain a supporting statement or medical records to support a prescribed diagnosis. A request for information was sent to the prescriber; however, no documentation was received. 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

You requested Lidocaine 2% gel prescribed for chest wall and rectal pain. The Part D plan denied your request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The documentation shows your doctor prescribed Lidocaine 2% gel to treat your chest wall and rectal 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 2% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Novolog FlexPen 100 units/milliliter prescribed for type 2 diabetes. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. 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 Novolog FlexPen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Latuda prescribed for major depressive disorder and anxiety. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The documentation shows your doctor prescribed Latuda to treat your major depressive disorder with psychotic symptoms and anxiety, unspecified. 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 Latuda.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Metolazone 5 milligram tablets prescribed for edema related to congestive heart failure. 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 include a physician supporting statement. A request for information was sent to the prescriber; however, no further documentation was received. 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.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 Repatha Pushtronex 420 milligram/3.5 milliliter injection prescribed monthly for hyperlipidemia. 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 Praluent (on the plans formulary) would not work for you since it can also be injected once a month. There is no evidence the Praluent was tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Fentanyl 25 microgram/hour transdermal patch prescribed for an unknown diagnosis. 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 amount of the medication. We did not receive the documentation requested.Your medical records show your doctor prescribed Fentanyl to treat your condition. However, your medical records do not support why an exception to the plans quantity limit is medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover the Fentanyl, as the drug exceeds the morphine equivalent dose threshold that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine 10 milligram tablets prescribed for muscle spasm of the back. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records submitted indicate that you have been prescribed Cyclobenzaprine 10 milligram tablets for muscle spasms of the back. However, the muscle spasms are documented to be associated with possible subtle right transverse process of a thoracic-one hairline fracture noted on an imaging scan of January 2017. The records do not support an acute musculoskeletal condition. Medicare approved compendia do not support the use of this drug for chronic muscle spasm conditions.  A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Forteo 620 microgram/2.48 milliliter solution pen-injector prescribed for post-menopausal osteoporosis. 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 Forteo to treat your post-menopausal osteoporosis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation supports you satisfy the plan's coverage criteria. The prescriber submitted a statement and medical records to support you were prescribed Forteo to treat your post-menopausal osteoporosis. The prescriber states there was an error in the previous submitted documentation and that you have not used a parathyroid hormone analog for more than 24 months during your lifetime. In addition, the medical records support you have a pre-treatment T-score less than or equal to -2.5 and you have failed prior treatment with an injectable osteoporosis treatment.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Glimepiride 4 milligram tablets prescribed for diabetes mellitus. 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 does not include a supporting statement. A request for a supporting statement was sent to your doctor; however, no further documentation was received. The documentation on hand 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

You requested Sandostatin LAR Depot 10 milligram vial prescribed one vial every 28 days for recurrent gastrointestinal bleeding. 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 Sandostatin to treat your recurrent gastrointestinal bleeding. 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 Sandostatin.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of non-formulary Keytruda 100 milligram per 4 milliliter solution prescribed for metastatic non-small cell lung cancer, EGFR mutation positive and a PD-L1 expression of 60%. The Part D plan denied the request stating the medication was being prescribed for a non-medically accepted indication.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 submitted medical records indicate that enrollee was initially diagnosed with EGFR mutated non-small cell lung cancer in 2018. The enrollee was initially treated with Tarceva; however, the cancer continued to progress. The enrollee was then treated with Tagrisso up until late December 2020 with tests obtained in January 2021 showing continued progression with extensive bony disease. Therefore, the enrollee was started on a regimen of Carboplatin, Keytruda, and Alimta.As outlined in the National Comprehensive Cancer Network guidelines, when the patient progresses on Tagrisso with multiple areas of metastatic disease, then it is recommended that patient is treated with first line systemic therapy options as if the patient has no mutation present. Per the National Comprehensive Cancer Network guidelines, Keytruda is a Category 1 recommendation for the treatment for recurrent, advanced, or metastatic non-small cell lung cancer as first-line therapy for PD-L1 expression-positive (1%) tumors that are negative for actionable molecular markers and with no present contraindications to PD-1 or PD-L1 inhibitors and performance status 0-2.  The guidelines further state that Keytruda is preferred to given in combination with Carboplatin and Alimta. As noted previously, the enrollee has an EGFR mutation and the documentation shows that the enrollees cancer has progressed despite being treated with two lines of EGFR inhibitor therapy. In this situation, it is recommended by the National Comprehensive Cancer Network guidelines to treat with systemic chemotherapy/immunotherapy. It is a Category 1 recommendation to be given as maintenance thereafter. Keytruda in not included in the plans formulary. However, as previously noted, the enrollee did not progress on EGFR inhibitors and treating further with EGFR inhibitors is not recommended by National Comprehensive Cancer Network. Therefore, no other formulary alternatives would be appropriate in this case. In summary, the submitted documentation supports the drug is being provided for a medically accepted indication as outlined in the National Comprehensive Cancer Network guidelines. Additionally, the documentation supports a formulary exception. A physician reviewed the appeal and determined that the plan is required to cover the Keytruda.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vascepa 1 gram capsule prescribed for hyperlipidemia and hypertriglyceridemia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The documentation shows your doctor prescribed Vascepa 1 gram capsule prescribed for hyperlipidemia and hypertriglyceridemia. The prescriber stated that the enrollee's pre-treatment triglycerides were less than 150 mg/dl.  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 Vascepa
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Zolpidem Tartrate ER 12.5 milligram extended release tablets. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Zolpidem Tartrate ER has been prescribed for sleep apnea, unspecified.  The prescriber clarified the diagnosis in the request for reconsideration dated 5/28/2021.  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 the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Belsomra 15 milligram tablets prescribed for insomnia. 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. Belsomra is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Belsomra at a lower cost tier level.