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

At issue is Quetiapine Fumarate 25 milligram tablet prescribed daily for Alzheimers disease, insomnia, and dementia. 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 Quetiapine Fumarate to treat the enrollees Alzheimers disease, insomnia, and dementia. 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 Quetiapine Fumarate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lynparza 100 milligram tablets prescribed for lung and colon cancer. 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.The submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There were no Medicare-approved peer-reviewed journal articles submitted to support the use of the drug for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 Mesalamine 800 -milligram DR tablets prescribed for ulcerative colitis and irritable bowel syndrome. The Part D plan denied the request for a tiering exception.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.We requested additional information from the prescriber. Specifically, we requested a prescriber statement to support all drugs available on the lower tiers of the formulary would not work for the enrollee.  Supporting medical records were requested.  However, we did not receive the requested information.Mesalamine DR 800 milligram tablet is a generic drug on Tier 4 of the plans formulary. The submitted documentation did not address why all the drugs available on the lower tiers of the plans formulary would not work. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amitiza 24 microgram capsule prescribed for irritable bowel syndrome with constipation. 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 the medication. Specifically, we asked for medical records to show why other medications on the plan's formulary would not work for the enrollee. However, we did not receive the documentation.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Amitiza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diazepam bulk powder 5 milligram compounded into suppository prescribed for unknown diagnosis. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 shows the Diazepam powder 5 milligram suppository is a compounded drug and each ingredient is reviewed individually. The Diazepam powder and Silica gel have not been approved by the Food and Drug Administration for both safety and effectiveness. Therefore, they do not meet the definition of Part D drugs and are not eligible for coverage under Medicare Part D. The PCCA MBK(Fatty Acid) base and Suppository Molds 1.3 milliliter are over-the-counter products and excluded for coverage under Part D. We determined the plan is not required to cover the requested compounded drug. 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 Sirturo 100-milligram tablet to treat bronchiectasis and non-tuberculous pulmonary mycobacterial infection (MAC, macrolide susceptible, non-cavitary). The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation does not 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 Tretinoin 0.1% Cream to treat solar elastosis. 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 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: Favorable

At issue is Vancomycin Hydrochloride 125-milligram capsules prescribed for clostridium difficile diarrhea. 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 requested additional information from the prescriber. Specifically, we requested medical records and a statement to support the enrollee met the plans prior authorization coverage criteria. We received the requested information and included it in the review.The submitted documentation indicates the prescriber ordered the requested drug for the enrollees noted condition. The prescriber submitted a statement to support the diagnosis. The Medicare approved compendia support the use of the drug for the enrollees condition. The plans prior authorization criteria have been met. A physician reviewed the appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Pregabalin 25-milligram capsules prescribed for diabetic peripheral neuropathy. 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 requested additional information from the prescriber. Specifically, we requested medical records and a statement to support the enrollee met the plans prior authorization coverage criteria. We received the requested information and included it in the review.The submitted documentation indicates the prescriber originally ordered the drug at issue for myalgia and myofascial pain. On appeal, the prescriber indicated the diagnosis was entered incorrectly and should be diabetic peripheral neuropathy. The prescriber submitted a statement and medical records to support the change in diagnosis. The Medicare approved compendia support the use of the drug for the clarified condition.  The prescriber also stated that the enrollee is intolerant to gabapentin.  The plans prior authorization criteria have been met. A physician reviewed the appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Glucagon 1 milligram per milliliter emergency kit prescribed for type 2 diabetes mellitus. 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. 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.  Note that Gvoke Hypopen is on the formulary in both the 1-pack and 2-pack.A physician reviewed the appeal and determined that the plan is not required to cover Glucagon.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gattex 5-milligram injection solution prescribed for an enrollee with severe diverticulitis complicated by bleeding and anemia status post a colectomy and loop ileostomy who is not dependent on nutrition. 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 requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee satisfies the plan's prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 Diclofenac Sodium 1% gel prescribed for unspecified osteoarthritis and low back 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 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 Diclofenac Sodium 1% gel was prescribed to treat unspecified osteoarthritis and low back pain. 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 Diclofenac Sodium 1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Lidocaine 5% ointment prescribed for Behcets disease. 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 requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement. We received a prescriber statement and included it in the review.On original appeal, the prescriber ordered the drug at issue for spondylosis without myelopathy or radiculopathy, cervical region, and complex regional pain syndrome of left lower limb. The prescriber submitted a statement to indicate the drug at issue is for the clarified diagnosis noted. There were no medical records submitted to support a change in diagnosis. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 Alcortin A gel 2 percent - 1 percent - 1 percent to treat vulvodynia. The Part D plan denied the request.  We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan denied the request for coverage because drugs classified as part of the Food and Drug Administrations (FDA's) Drug Efficacy Study Implementation (DESI) program cannot be covered by the Medicare Part D drug benefit. These drugs are considered to be Less than Effective (LTE) per FDA review. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Abilify 400-milligram maintenance injection prescribed for schizophenia. The Part D plan denied coverage.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 records submitted at the reconsideration level. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee satisfies the plan's prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.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 Taltz 80 milligram/milliliter auto-injector prescribed to treat plaque psoriasis. 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.The prescriber indicates this is a continuation of treatment and there has been improvement since beginning treatment with Taltz. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plans prior authorization requirements for continuation of treatment were met. A physician reviewed your appeal and determined that the plan is required to cover Taltz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Mesalamine DR 800-milligram tablet to treat Crohns disease, unspecified without complications. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 asked your prescriber to send us a prescriber statement, answers to tiering exception coverage criteria, safety of the drug, and medical records. However, we did not receive the documentation.Mesalamine DR is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the request and determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 100-milligram tablet to treat chronic fatigue related to multiple sclerosis. 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 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: Favorable

At issue is Ferriprox 1000 milligram tablet prescribed for superficial siderosis. 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. The prescriber indicates Ferriprox 1000 milligram tablet is prescribed for superficial siderosis which is a rare neuro-degenerative disease caused by the iron buildup on the brain from iron overload. The prescriber states the drug remains one of the few treatment options available for this rare debilitating disease. This drug has an orphan drug designation for the treatment of superficial siderosis. The drug is not on the plans formulary but there are no other drugs on the plans formulary that are approved to treat this disease. The chelating agents on the plans formulary are not approved to treat superficial siderosis and the drug Ferriprox, is the best known drug for this rare disease. A physician reviewed your appeal and determined that the plan is required to cover Ferriprox.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Pregabalin 50 milligram capsules. 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 Pregabalin has been prescribed for the treatment of pain associated with a current shingles infection. 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 Mycophenolate Mofetil 500 milligram tablets prescribed to treat the enrollee with interstitial lung disease and rheumatoid arthritis. The Part D plan denied the appeal 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 Mycophenolate Mofetil 500 milligram tablets  to treat interstitial lung disease and rheumatoid arthritis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Mycophenolate Mofetil 500 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Dimethyl Fumarate 240-milligram direct release capsules prescribed for multiple sclerosis. The Part D plan denied the request stating the enrollee was receiving the drug at issue through a patient assistance program. 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 requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed. However, we did not receive the requested information.The submitted documentation did not indicate that all the formulary alternatives were tried and would be ineffective. Of note, the submitted documentation includes a letter that indicates the enrollee is no longer receiving the drug at issue through a patient assistance program.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 Jardiance 25 milligram tablet. 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. Jardiance 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.