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

At issue is Taltz 80 milligram/milliliter solution auto injector prescribed as directed for plaque psoriasis and 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.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.Your medical records show your doctor prescribed Taltz to treat your plaque psoriasis and plaque psoriasis. 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 Taltz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron Hydrochloride 4 milligram tablets prescribed to treat an enrollee with lupus coagulant syndrome with unspecified nausea and vomiting. 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 Ondansetron Hydrochloride 4 milligram tablets to treat lupus coagulant syndrome with unspecified nausea and vomiting. 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 Ondansetron Hydrochloride 4 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyanocobalamin 1000 microgram/milligram prescribed for vitamin deficiency. 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 drug requested is a prescription vitamin. Vitamins and minerals are excluded from coverage under Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Cyanocobalamin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligram tablets prescribed for moderate to severe plaque psoriasis. 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee met the plans prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation indicates the prescriber ordered Otezla to treat moderate to severe plaque psoriasis. The 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 the appeal and determined that the plan is not required to cover Otezla. 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 a request for coverage of Scopolamine 1 milligram per 72 hour transdermal patches. 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 prescriber has indicated at reconsideration that Scopolamine has been prescribed for the treatment of central vertigo. 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. Additionally, medical records were not submitted to support the diagnosis of central vertigo. 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 Repatha SureClick 140 milligrams per milliliter solution auto-injector prescribed to treat coronary artery disease. 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.Repatha SureClick is 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 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. 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 the appeal and determined that the plan is not required to cover Repatha SureClick 140 milligrams per milliliter solution auto-injector.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Albuterol Sulfate 108 micrograms per actuation aerosol solution prescribed to treat chronic obstructive pulmonary disease. 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.On redetermination, the Part D plan denied the appeal request stating Albuterol Sulfate was not on the plans formulary. However, the QIC found that Albuterol Sulfate, a generic drug, is on the plans formulary. There are no prior authorization criteria for this drug. Therefore, the requested drug, in generic form, is eligible for coverage under Medicare Part D. Additionally, Medicare approved compendia support Albuterol Sulfate as a medically accepted indication. Upon reconsideration, the prescriber indicates that the brand drug, ProAir Hydrofluoroalkane (HFA) is being requested. The plan has to conduct a redetermination (first level of appeal) before we can review the case for ProAir HFA. The case must first be appealed to the plan, if they review the case and make an unfavorable or a partially favorable decision, then the case can be filed for a reconsideration (second level of appeal) with us.A physician reviewed the appeal and determined that the plan is required to cover only the generic drug, Albuterol Sulfate 108 micrograms per actuation aerosol solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mavenclad 10 milligram X 10 tablet pack prescribed as directed for multiple sclerosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Mavenclad.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Tadalafil 20 milligram tablets. The Part D plan denied the request stating that drugs prescribed for the treatment of erectile dysfunction are excluded from Medicare Part D 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 submitted medical records support that Tadalafil is not being prescribed for the treatment of erectile dysfunction; rather, the drug has been prescribed for the treatment of the enrollees pulmonary arterial hypertension, which is a medically accepted indication outlined in the Medicare approved compendia. However, Tadalafil is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale as to why all the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Northera 100 milligram capsules prescribed for neurogenic orthostatic hypotension. 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 documentation submitted indicates the prescriber ordered Northera to treat neurogenic orthostatic hypotension. The plan has prior authorization requirements for this drug that must be met before the plan will cover the requested drug. 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 Northera. 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

You requested Budesonide Suspension 0.5 milligram/2 milliliter prescribed as directed for eosinophilic esophagitis. 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 Budesonide to treat your eosinophilic esophagitis. 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 Budesonide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Premarin 0.9 microgram tablets prescribed for decreased estrogen levels secondary to surgical removal of the ovaries. 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. Premarin tablets are not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale as to why all of the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Temazepam 30 milligram capsules prescribed for insomnia. 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 a prescriber statement to support the enrollee met the plans prior authorization coverage criteria. However, we did not receive the requested information.The documentation on hand 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: Unfavorable

At issue is a request for coverage of Sildenafil Citrate 20 milligram tablets. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. The documentation indicates that Sildenafil Citrate has been prescribed for the treatment of end-stage right heart failure following cardiac surgery. 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 Entresto 24-26 milligram tablets prescribed for chronic heart failure. 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.Entresto 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 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 Dronabinol 10 milligram capsule prescribed for nausea due to antiretroviral therapy. 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 records submitted at the reconsideration level. The documentation submitted indicates Dronabinol is prescribed for nausea due to antiretroviral therapy. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Megace 400 milligram/10 milliliter suspension prescribed for anorexia. 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 Megace because it was prescribed for anorexia. 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, the enrollee must pay for them. 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 Dronabinol 2.5 milligram capsules prescribed for anorexia from chemotherapy. 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 Dronabinol because it was prescribed for anorexia. 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, the enrollee must pay for them. 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 Trulance 3 milligram tablets prescribed for irritable bowel syndrome with constipation and opioid-induced constipation. 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 for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Trulance.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spravato 84 milligram spray prescribed for major depressive disorder. 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 Spravato because it was a repackacked drug. Repackaged drugs are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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: Favorable

At issue is a prior authorization request for Benlysta 200 milligram/milliliter solution prescribed for systemic lupus erythematosus and lupus nephritis. 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. The documentation submitted indicates the prescriber ordered Benlysta for the enrollees systemic lupus erythematosus and lupus nephritis. The Medicare approved compendia support the use of Benlysta for the enrollees condition. The enrollee has been diagnosed with autoantibody-positive, systemic lupus erythematosus and lupus nephritis. The enrollee is currently being treated with an anti-malarial drug for the condition. Furthermore, the enrollee does not have severe active central nervous system lupus. The enrollee meets the plans prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested biologic is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xiidra 5% solution prescribed for dry eye 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.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 the appeal and determined that the plan is not required to cover Xiidra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alprazolam 1 milligram extended release tablet prescribed for generalized anxiety disorder and depression. 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 for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Alprazolam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligram tablets prescribed for unspecified 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 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 submitted documentation indicates the prescriber ordered Zolpidem Tartrate to treat unspecified insomnia. The 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 the appeal and determined that the plan is not required to cover Zolpidem Tartrate. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.