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

You requested Topiramate 50 milligram tablet prescribed Tourettes syndrome. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Topiramate for Tourettes syndrome. 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 Topiramate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil Citrate 20 milligram oral tablet prescribed daily for erectile dysfunction. 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. We determined that the plan is not required to cover Sildenafil Citrate because it was used to treat sexual or erectile dysfunction. 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

At issue is Morphine Sulfate ER 50 milligram capsules prescribed as directed for chronic 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. 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 Morphine Sulfate ER 50 milligram capsules.
Appeal type: Prescription Drug
Decision: Favorable

You requested Oxervate 20 microgram/milliliter solution. At initial determination and redetermination the diagnosis of herpes zoster eye disease was given. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication(s).  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.At reconsideration a diagnosis of recurrent corneal erosion, neurotrophic, secondary to herpes zoster was given. Medical records were provided by the prescriber, dated June 1, 2021, to support this diagnosis. Herpes keratitis is the most common cause of neurotrophic keratitis. It could be determined that the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is eligible for coverage under Medicare Part D.This drug has prior authorization criteria that are satisfied for approval of this drug. The plan is required to cover this medication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafanil 150 milligram tablets prescribed for hypersomnia. 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 Armodafanil for hypersomnia. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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

You requested Cyclobenzaprine Hydrochloride 5 milligram tablets prescribed as directed for treatment of migraine headaches. 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 Cyclobenzaprine Hydrochloride for treatment of migraine headaches. 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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyproheptadine Hydrochloride  4 milligram tablets prescribed as directed for loss of appetite. 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 doctor prescribed Cyproheptadine Hydrochloride to act as an appetite stimulant and encourage weight gain for an enrollee with loss of appetite. Drugs prescribed to treat anorexia, weight loss, or weight gain 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.We determined that the plan is not required to cover Cyproheptadine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Skyrizi 150 milligram per 1 milliliter syringe kit prescribed one at week zero, one at week four, then one every 12 weeks 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 information submitted at the reconsideration level.The medical records show the doctor prescribed Skyrizi to treat the enrollees 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 Skyrizi. 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 a prior authorization for Lidocaine-Prilocaine 2.5%-2.5% cream. 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 does not contain a supporting statement or medical records to support a prescribed diagnosis. 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

You requested Apraclonidine Hydrochloride 0.5% ophthalmic solution prescribed to instill 1 drop in affected eye 3 times daily to treat eyelid ptosis resulting from the administration of Botox. 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 Apraclonidine Hydrochloride 0.5% ophthalmic solution to treat eyelid ptosis resulting from the administration of Botox. 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 Apraclonidine Hydrochloride 0.5% ophthalmic solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Actemra 20 milligram/10 milliliter prescribed for end state renal disease and awaiting organ transplant status. 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 Actemra to treat your end state renal disease and awaiting organ transplant status. 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 Actemra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets prescribed as directed for small intestinal bacterial overgrowth. 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 Xifaxan to treat your small intestinal bacterial overgrowth. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carvedilol Phosphate extended-release 80 milligram extended-release 24-hour capsules prescribed to treat hypertension. 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.This medication is not on your plan's list of medications. The prescriber has not given a clear medical reason why medications on that list did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. 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.A physician reviewed your appeal and determined that the plan is not required to cover Carvedilol Phosphate extended-release 80 milligram extended-release 24-hour capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colistimethate Sodium for solution 150 milligram via nebulizer prescribed for recurrent pseudomonas aeruginosa infections. 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. Colistimethate Sodium is not Food and Drug Administration-approved for inhalation via a nebulizer.  Therefore, the requested drug is excluded Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armodafinil 150 milligram tablet prescribed daily for hypersomnia due to obstructive sleep apnea. 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 Armodafinil to treat the enrollees hypersomnia due to obstructive sleep apnea. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollee has obstructive sleep apnea and has been on a continuous positive airway pressure device for years. However, the prior authorization requirements indicate a diagnosis of obstructive sleep apnea must be confirmed by polysomnography. 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 Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a prior authorization for Sildenafil Citrate 25 milligram tablets prescribed for pulmonary hypertension, World Health Organization Group II. 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 Sildenafil Citrate for pulmonary hypertension, World Health Organization Group II. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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

You requested Oxycontin ER 40 milligram tablet prescribed one tablet four times a day for chronic pain. The Part D plan denied your request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. A request was submitted to the prescriber to provide a diagnosis, to address the off-formulary 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 Ropinirole Hydrochloride ER 4 milligram tablets prescribed as directed for restless leg syndrome. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. 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. Additionally, formulary drugs should be attempted to the maximum FDA approved and tolerated daily dosage before non-formulary alternatives can be approved. In this case, the medical records do not support why other drugs or dosages on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Ropinirole Hydrochloride ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 2 milligram sublingual tablet prescribed 0.5 tablet twice daily for chronic low back and left leg pain due to degeneration of lumbar or lumbosacral disc. 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 Buprenorphine Hydrochloride to treat the enrollees chronic low back and left leg pain due to degeneration of lumbar or lumbosacral disc. At reconsideration a diagnosis of opiod dependence in remission was given. No medical records were provided by the prescriber to support this diagnosis. The Medicare approved compendia do not support the use of this form of this drug for the conditions documented. A physician reviewed the appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lorazepam 1 milligram tablet prescribed for fibromyalgia. 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 Lorazepam 1 milligram tablet was prescribed for fibromyalgia. 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 Lorazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Ofev 150 milligram oral capsule. 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.Your medical records show your doctor prescribed Ofev to treat your progressive fibrosing interstitial lung disease. 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 Ofev. 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 Lidocaine 5% patch 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. The documentation shows your doctor prescribed Lidocaine 5% patch to treat your acute low back 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cresemba 186 milligram capsule prescribed for prophylaxis of invasive aspergillosis and other invasive fungal disease in an immunocompromised allogeneic stem cell transplant recipient. 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 Cresemba as prophylaxis for invasive aspergillosis and other invasive fungal disease. However, the Medicare approved compendia do not support the use of this drug for the prevention of these conditions. A physician reviewed the appeal and determined that the plan is not required to cover Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Lokelma 5 gram powder packet prescribed for hyperkalemia. 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. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Lokelma.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Stelara 90 milligrams per milliliter pre-filled syringe prescribed to treat hidradenitis suppurativa. 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 Stelara 90 milligrams per milliliter pre-filled syringe to treat hidradenitis suppurativa. 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 Stelara 90 milligrams per milliliter pre-filled syringe.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram capsules prescribed as an appetite stimulant. 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.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. 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.