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

At issue coverage for Taltz Autoinjector (2 pack) 80 milligram per milliliter subcutaneous auto injection pen prescribed for plaque psoriasis and psoriatic arthritis. 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. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Flector 1.3% patch prescribed daily for chronic pain. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Flector 1.3% patch to treat the enrollees chronic pain. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Flector 1.3% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol 90 microgram inhaler prescribed daily for chronic obstructive pulmonary 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. Albuterol 90 microgram inhaler is not on the plan's formulary.  Ventolin HFA 90 microgram inhaler is on the plan's formulary. 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 the Albuterol inhaler.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligrams per milliliter to treat hyperlipidemia in an enrollee with coronary artery disease.   The Part D plan denied the request.  The requested drug is not on the plans formulary. 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 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 Hyoscyamine Sulfate 0.125-milligram tablet to treat generalized abdominal pain. 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.The plan denied the request for coverage of the requested drug to treat the provided diagnosis because the plans Medicare Part D drug plan cannot cover drugs classified as being part of the Food and Drug Administration (FDA)'s Drug Efficacy Study Implementation (DESI) program. These drugs are considered to be Less than Effective (LTE) per FDA review.A physician reviewed the appeal and determined that the requested drug is excluded from Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Amitiza 24-microgram capsule to treat irritable bowel syndrome with constipation. 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 provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. As noted in the physician progress note dated April 28, 2021, the beneficiary was trialed on Linzess, Trulance, Movantik, and several combinations without relief. Therefore, an exception to the plans formulary coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Tymlos 3120 microgram per 1.56 milliliter subcutaneous injection pen. The Part D plan denied the request because the prior authorization requirements were not met, as the prescriber indicated that the enrollee was not being treated for postmenopausal osteoporosis. 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 Tymlos has been prescribed for osteoporosis in a male. However, the only acceptable use for Tymlos noted in the Medicare approved compendia is for the management of osteoporosis in postmenopausal women who are at high risk for fractures. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gammaplex 10 grams per 100 milliliter, 40 grams prescribed daily for five days every four weeks for inclusion body myositis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Gammaplex to treat the enrollees inclusion body myositis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. It is not a medically accepted indication per Medicare rules.A physician reviewed your appeal and determined that the plan is not required to cover Gammaplex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 10 milligram oral tablet.  At initial determination and redetermination the diagnosis of chronic pain syndrome was given. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  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.At reconsideration a diagnosis of fibromyalgia was given. The medical records provided by the prescriber did not support this diagnosis change. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate HFA aerosol solution 108 (90 base) micrograms per actuation. There was no documented 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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the requested documentation.There were no medical records submitted supporting a diagnosis for use of this drug. The QIC is unable to determine if your condition is a medically-accepted indication to support the use of the requested drug.A physician reviewed your appeal and determined that the plan is not required to cover Albuterol Sulfate HFA aerosol solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Victoza 3-Pack 18 milligram per 3 milliliter prescribed for obesity. 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.We determined that the plan is not required to cover Victoza because it was used to treat obesity. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, they must pay for it themselves. 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 Linzess 145 microgram capsule prescribed daily for chronic constipation. 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. Linzess 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 Jakafi 10 milligram tablets prescribed for gamma delta T-cell lymphoma. 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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested.The documentation shows the doctor prescribed Jakafi to treat gamma delta T-cell lymphoma. The prescriber states the enrollee was previously treated with Etoposide and Dexamethasone, as well as Brentuximab. The provider states that most recently, the enrollee was treated with Cytoxan, Doxorubicin, and Prednisone, in combination with Brentuximab. The prescriber states the enrollee experienced disease progression despite treatment. However, medical records were not submitted to support the enrollees treatment regimen, or to show the providers consideration for treatment with drugs supported by the Medicare-approved compendia. The prescriber submitted medical literature for review, but medical records were not submitted to support that the enrollee is using the requested drug in accordance with the published study. It could not be determined whether the requested drug was prescribed for a medically accepted indication.  A physician reviewed your appeal and determined that the plan is not required to cover Jakafi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Temazepam 15 milligram capsules prescribed for insomnia. 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. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not validated by the provided medical records. 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 Hysingla ER 20 milligrams 24-hour deterrent tablet to treat the enrollees condition. 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 to show why you need this medication. We did not receive the requested documentation.Hysingla ER 20 milligrams 24-hour deterrent tablet was prescribed to treat your condition. 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 Hysingla ER 20 milligrams 24-hour deterrent tablet. There was no documentation supporting the plans coverage criteria. 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 Leukine 250 microgram vial prescribed for Alzheimers disease. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your prescriber indicated that Leukine is prescribed to treat Alzheimers disease. 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 Leukine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone Hydrochloride Extended Release 10 milligram tablets prescribed for chronic pain 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. 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 Gamunex-C 5-milligrams/50-milliliters to treat necrotizing autoimmune myopathy. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 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 Quinine Sulfate 324-milligram capsule to treat sleep related leg cramps. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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. Per the Medicare approved compendia, MicroMedex, The risk associated with the use of quinine outweighs the benefits for the treatment or prevention of leg cramps. Therefore, it should not be used for the prophylaxis or treatment of nocturnal leg cramps. 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 Tretinoin 0.025% Cream prescribed once to twice a week for sun damage/other skin changes due to chronic exposure to nonionzing radiation. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation shows your doctor prescribed Tretinoin 0.025% Cream to treat your sun damage/other skin changes due to chronic exposure to nonionzing radiation. 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 Tretinoin 0.025% Cream. 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 Humira Pen Injector Kit 40 milligram/0.8 milliliter prescribed for Reiters 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. Your prescriber indicated that Humira Pen Injector Kit is prescribed to treat Reiters disease. 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 Humira Pen Injector Kit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Omega-3-Acid Ethyl Esters 1 gram capsule to treat degenerative disease of the nervous system.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 Omega-3-Acid Ethyl Esters 1 gram capsule to treat degenerative disease of the nervous system. 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 Omega-3-Acid Ethyl Esters 1 gram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol sulfate 2.5 milligram/3 milliliter vial, 540 milliliters per 60 days prescribed for chronic obstructive pulmonary disease. The Part D plan denied your requestWe 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 Albuterol sulfate is being administered through a nebulizer for use in the home setting. Medicare Part B covers supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to reimburse for the Albuterol sulfate. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Nuedexta 20-10 milligram capsules. 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 documentation indicates that Nuedexta has been prescribed for the treatment of pseudobulbar affect associated with Huntingtons disease. The use of Nuedexta has been approved by the Food and Drug Administration for the treatment of pseudobulbar affect. Therefore, the medication is being prescribed for a medically accepted indication.  However, the plan has prior authorization requirements that have to be satisfied before covering Nuedexta. During this review, a request was submitted to the prescriber to address the plans coverage criteria for the medication. However, the prescriber did not respond to the request. The submitted documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.