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

At issue is Sirolimus 1 milligram tablet to treat pure red cell aplasia. 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 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

You requested the off-formulary Nulojix 250 milligram solution prescribed intravenously every 6 months for post kidney transplant. 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 also researched Medicare systems and reviewed the enrollment data available. The documentation shows your doctor prescribed Nulojix 250 milligram to treat your post kidney transplant. 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 Nulojix 250 milligram.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Tolterodine Tartrate 4 milligram extended release capsules prescribed for severe urge incontinence. 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. Tolterodine Tartrate 4 milligram extended release capsules are not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives that are 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 a request for coverage of Repatha SureClick 140 milligram per milliliter subcutaneous injection pen. The Part D plan denied the request because the drug was not included on the plans formulary and the documentation did not support a formulary 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.The submitted medical records indicate that Repatha SureClick has been prescribed for the treatment of unspecified hyperlipidemia without the presence of established cardiovascular disease. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for 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. Since the drug is not eligible for coverage under Medicare Part D, a formulary exception is not applicable to this review. 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 Ofev 100 milligram capsule prescribed twice a day for idiopathic pulmonary fibrosis. 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 requested additional information from your prescriber but did not receive a response. There were no medical records to support the reported diagnosis or to determine if the drug at issue was medically indicated for your condition.  A physician reviewed your appeal and determined that the plan is not required to cover Ofev.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Erbitux 200 milligram/100 milliliter intravenous solution prescribed for malignant neoplasm of tongue. 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 Erbitux for malignant neoplasm of tongue. The submitted documentation does not include medical records to support previous treatments. The Medicare approved compendia do not support the use of the biologic at issue for your condition. As the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Venclexta 100 milligram tablet prescribed four tablets daily for Waldenstrom macroglobulinemia. 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 records submitted at the reconsideration level. The medical records show the doctor prescribed Venclexta to treat the enrollees Waldenstrom macroglobulinemia. However, the Medicare approved compendia do not support the use of the requested drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Venclexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone Hydrochloride 10 milligram tablets prescribed to treat low back pain.The QIC 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 QIC asked the prescriber to send us information regarding the Enrollees condition. We also asked for medical records or other documentation to verify or clarify the medical necessity for the Enrollee to take both Oxycodone and Alprazolam. We did not received the requested medical records.The documentation shows the doctor prescribed Oxycodone Hydrochloride 10 milligram tablets to treat low back pain. The plan has prior authorization requirements with safety concerns for this drug that must be met before they will cover the requested drug. The documentation shows the Enrollee is taking a benzodiazepine (Alprazolam), which is a potential drug interaction or contraindication with the addition of the high-risk medication (Oxycodone Hydrochloride). There were no medical records received to verify or clarify the medical necessity for the use of an opioid and benzodiazepine. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Oxycodone Hydrochloride 10 milligram tablets, as the prior authorization criteria with safety concerns were not satisfied. 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 Horizant extended release (ER) 600 milligram tablet. At initial determination and redetermination the diagnosis of complex regional pain syndrome was given. 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 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 level a diagnosis of restless legs syndrome was added. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records and other documentation to show why the medication is needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. We received the documentation and included it in our review.The medical records reveal a diagnosis of restless legs syndrome. The Medicare approved compendia do support the use of the requested drug for the diagnosis of restless legs syndrome. However, 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 Horizant ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Verzenio 200 milligram tablets prescribed for metastatic breast 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 Verzenio for metastatic breast cancer. The submitted documentation does not support the enrollee is using the drug in combination with either an aromatase inhibitor or fulvestrant. There is no indication of disease progression following endocrine therapy and prior chemotherapy in the metastatic setting. The Medicare approved compendia do not support the use of the drug at issue for your condition. 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 Tazorac 0.1% cream prescribed daily for lamellar ichthyosis. 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 enrollees doctor prescribed Tazorac to treat lamellar ichthyosis. However, the Medicare approved compendia do not support the use of the requested drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Tazorac.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Xolair 75 milligram/0.5 milliliter injection prescribed for severe persistent allergic asthma. 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 records submitted at the reconsideration level. The enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee was prescribed Xolair for severe allergic asthma, is older than 12 years of age, is taking a maximally-dosed combination inhaled corticosteroid/long-acting beta2-agonist agent, and has documentation of a positive skin test to a perennial aeroallergen.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 Azathioprine 50 milligram tablet prescribed daily for stiff man syndrome. 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 Enrollees doctor prescribed Azathioprine to treat the Enrollees stiff man syndrome. However, the Medicare approved compendia do not support the use of the requested drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 10 milligram tablet prescribed for pulmonary hypertension. The Part D plan denied the request stating the drug is excluded from coverage under Part D. 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 records submitted at the reconsideration level. We requested additional information from your prescriber but did not receive all documents requested. There were no medical records to support the reported diagnosis or to support the prior authorization requirements were met.   A physician reviewed your appeal and determined that the plan is not required to cover Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nexletol 180 milligram oral tablet. 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.You requested Nexletol for the provided diagnosis of hyperlipidemia. However, the Medicare approved compendia do not support the use of this drug for the noted condition. In addition, no medical records have been submitted for review to clarify this issue. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication. The prior authorization 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 Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Quad-Mix injection prescribed for erectile dysfunction. The Part D plan denied the enrollees request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is not required to cover Quad-Mix injection. According to your plans Evidence of Coverage, drugs prescribed to treat sexual/erectile dysfunction are excluded from coverage under Medicare Part D. Medicare rules state drugs that do not meet the definition of a Part D drug, as approved by the Food and Drug Administration for safety and effectiveness, are excluded from coverage. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Tri-Mix injection prescribed for erectile dysfunction. The Part D plan denied the enrollees request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is not required to cover Tri-Mix injection. According to your plans Evidence of Coverage, drugs prescribed to treat sexual/erectile dysfunction are excluded from coverage under Medicare Part D. Medicare rules state drugs that do not meet the definition of a Part D drug, as approved by the Food and Drug Administration for safety and effectiveness, are excluded from coverage. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin 15 milligram tablet prescribed for 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 your prescriber to send us information regarding the Enrollee's condition. We also asked for medical records or other documentation to show why the medication is needed Specifically, we asked for records to show why other medications on the plan's formulary would not work. 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 Oxycontin
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 72 microgram capsule prescribed daily for unknown diagnosis. The Part D plan denied the Enrollees 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. A request was submitted to the prescriber to provide a diagnosis, to address the plan's nonformulary 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

At issue is a prior authorization request for Opsumit 10 milligram tablets. 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 does not include a supporting statement or medical records. A request for information was sent to the prescriber; however, no further 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

At issue is Modafinil 200 milligram tablet prescribed twice daily for daytime somnolence associated with traumatic brain injury. 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 enrollees doctor prescribed Modafinil to treat daytime somnolence associated with traumatic brain injury. However, the Medicare approved compendia do not support the use of the requested drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xiidra 5% eye drops prescribed for the enrollees condition. 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.Xiidra is a non-formulary drug. Non-formulary drugs are 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 Restasis 0.05 percent ophthalmic drops 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. Restasis is a brand drug on Tier 2 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem 10 milligram tablet prescribed daily for insomnia. 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 documentation indicates the doctor prescribed Zolpidem to treat the Enrollees insomnia. The drug at issue is a high-risk drug and can only be approved for 90 tablets every 365 days. An exception to the quantity limit criteria was not met.Therefore, the plan is not required to cover Zolpidem for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lyrica 150 milligram capsules prescribed as directed for other chronic postprocedural pain. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The documentation shows your doctor prescribed Lyrica to treat your other chronic postprocedural 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 Lyrica.