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

You requested Toprol XL 50 milligram ER tablets prescribed for paroxysmal supraventricular tachycardia. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates your doctor prescribed Toprol XL for paroxysmal supraventricular tachycardia. The prescriber has not indicated 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 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 Budesonide-formoterol fumurate 160-4.5 microgram aerosol inhalation prescribed as directed for chronic obstructive pulmonary disease and asthma. The Part D plan denied the request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the plans formulary exception criteria. A response from the prescriber was not received. The current records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover the Budesonide-formoterol fumurate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets prescribed twice daily for hepatic encephalopathy. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your physician submitted a supporting statement. The statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for Tacrolimus 0.5 milligram capsules prescribed daily following a bone marrow/stem cell transplant. The Part D Plan denied the request.  We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your records show your doctor prescribed Tacrolimus to prevent rejection following a bone marrow/stem cell transplant. Based on the information provided, the drug is eligible for Part B coverage. Therefore, the drug is not eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is not required to cover Tacrolimus.
Appeal type: Prescription Drug
Decision: Favorable

You requested Entresto 97 milligrams-103 milligram tablet prescribed twice daily for chronic combined systolic and diastolic congestive heart failure. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. 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 received the documentation and included it in our review.Your medical records show your doctor prescribed Entresto to treat your congestive heart failure. The Medicare approved compendia supports the use of this drug for your condition. The plan's coverage criteria has also been satisfied. The prescriber submitted a statement and medical records to support you are diagnosed with congestive heart failure New York Heart Association Functional Classification II.A physician reviewed your appeal and determined that the plan is required to cover Entresto.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pristiq 100 milligram extended-release oral tablet prescribed daily for anxiety disorder. The Part D plan denied your request because the requested drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The records show Pristiq was prescribed to treat anxiety disorder. At reconsideration the prescriber submitted a supporting statement indicating the patient also has coproporphyria. However, the Medicare approved compendia do not support the use of this drug for this condition. As such, the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Pristiq.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis 0.05% emulsion prescribed for keratoconjunctivitis sicca. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The 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

You requested Xhance 93 microgram nasal spray prescribed for hypertrophy of nasal turbinates. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates your doctor prescribed Xhance for hypertrophy of nasal turbinates. The Medicare approved compendia do not support the use of this drug for your condition. 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 Cinacalcet hydrochloride 30 milligrams prescribed as directed to treat hypercalcemia. 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.No medical records were provided by the prescriber. 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.A physician reviewed your appeal and determined that the plan is not required to cover the Cinacalcet hydrochloride because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Cyclobenzaprine Hydrochloride 10 milligram tablets. 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.The documentation indicates that Cyclobenzaprine Hydrochloride has been prescribed for pain management due to chronic musculoskeletal conditions including low back pain. 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 your appeal and determined that the plan is not required to cover Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Livalo 4 milligram tablets for the treatment of hyperlipidemia. 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. Livalo is not included in the plans formulary. The prescriber has not sufficiently addressed why all alternative medications included in the plans formulary to treat the noted 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 Droxidopa 200 milligram capsule prescribed three times daily for orthostatic hypotension. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level. The record shows that your doctor prescribed Droxidopa to treat your condition. There are no medical records to support the plans prior authorization criteria have been met. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Droxidopa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira 40 milligram pen injection kit. 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 indicates that Humira is prescribed to treat pyoderma gangrenosum. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vraylar 3 milligram capules prescribed as directed. 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 additional information to support the medical necessity of the requested drug. However, we did not receive the documentation.At redetermination, a diagnosis of schizophrenia was given. However, no medical records were provided by the prescriber to support the enrollees diagnosis. 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.A physician reviewed your appeal and determined that the plan is not required to cover Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lenvima 20-milligram capsule Therapeutic Pack to treat colorectal cancer. 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 treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.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 Dilantin 100 milligram capsules (Branded) prescribed twice daily for seizure disorder. 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. Dilantin is a brand drug on Tier 4 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan, 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 your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Movantik 25 milligram tablets prescribed daily for opioid induced constipation. The Part D plan denied your request.We performed and 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. Movantik 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 to treat the enrollee's condition. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 30 milligram capsules prescribed to treat fatigue related to multiple sclerosis.  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. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vardenafil 20 milligram tablets prescribed as directed for erectile dysfunction and benign prostatic hyperplasia. 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. We determined that the plan is not required to cover Vardenafil. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Atovaquone 750 milligram per 5 milliliter oral suspension prescribed for pneumocystis pneumonia prophylaxis. 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 does not satisfy the plans prior authorization requirements. The prescriber has not sufficiently addressed the plans coverage criteria for this medication. 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 Procrit 40000 unit/milliliter solution for anemia in chronic kidney disease. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Procrit to treat your anemia in chronic kidney disease. The Medicare approved compendia do support the use of this drug for your condition. The plan requires the enrollee have an increase in hemoglobin of at least one gram per deciliter as a result of using the requested drug before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria. At initial determination and redetermination the prescriber answered no to the question regarding hemoglobin levels. Upon reconsideration the prescriber submitted a supporting statement indicating the enrollee has had an increase in hemoglobin of a least one gram per deciliter. However, the medical records do not reflect this information. A physician reviewed your appeal and determined that the plan is not required to cover Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lynparza 150 milligram tablet to treat T3N0M0 pancreatic adenocarcinoma. 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 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: Favorable

At issue is Levalbuterol to treat asthma. We received a coverage determination request.We performed an independent and de novo review. To make our decision, we read the limited records provided carefully. We reviewed all documentation submitted.The prescriber has provided patient specific clinical rationale, supported by medical records, as to why Levalbuterol is medically necessary for this patient. It is on the plans formulary and being used for a medically accepted indication. As such, the plan is required to cover Levalbuterol. 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 Heparin Sodium 5000 units prescribed for deep vein thrombosis prophylaxis. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your physician did not submit a supporting statement or medical records. A request for a statement and medical records was submitted to your physician; however, no documentation was received. As it cannot be determined that you have a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested Zarxio 300 micrograms/0.5 milliliters subcutaneous injection prescribed as directed for an enrollee with mantle 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. The record shows the provider prescribed Zarxio for the prophylaxis of febrile neutropenia in an enrollee with mantle cell lymphoma who is receiving high dose chemotherapy. The prescriber statement and medical records indicate the enrollee is not receiving Zarxio on the same day as chemotherapy or radiation. The medical records show the enrollee is receiving Zarxio on day five of the treatment cycle. The Medicare approved compendia indicate Zarxio should not be administered within 24 hours of cytotoxic chemotherapy; the documentation shows the drug is being administered in accordance with Medicare guidelines. In addition, the documentation shows the enrollee has satisfied the plans prior authorization criteria that Zarxio cannot be administered on the same day as myelosuppressive chemotherapy or therapeutic radiation.A physician reviewed your appeal and determined that the plan is required to cover the Zarxio.