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

You requested Wakix 4.45 milligram tablets prescribed for idiopathic 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 Wakix for idiopathic hypersomnia. 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

You requested Lidocaine Ointment 5% prescribed for low back pain. 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. We also researched Medicare regulations and Medicare approved compendia. We requested additional information from the prescriber but did not receive a response. Medicare approved compendia does 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 Ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Desvenlafaxine Succinate 50 milligram ER tablets prescribed for bipolar disorder. 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 originally prescribed Desvenlafaxine Succinate ER for bipolar disorder. Your doctor indicated the diagnosis should be post-traumatic stress disorder. 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: Favorable

At issue is Leflunomide 20 milligram oral tablet prescribed daily for rheumatoid arthritis. 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. We asked your prescriber to send us information about your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why similar medications on the lower tiers would not work for you. We received the documentation and included it in our review.Your medical records show your doctor prescribed Leflunomide to treat your seronegative rheumatoid arthritis. Leflunomide is a generic drug on Tier 3 of the plans formulary. The plans formulary includes alternative drugs of the same type on Tiers 1 and 2 ; therefore, a tier exception may be considered.In this case, the medical records show Methotrexate is contraindicated due to enrollees history of pulmonary fibrosis but medical records submitted do not support this diagnosis.  Methotrexate in an injectable form is also on the plan's formulary in addition to oral formulations, The enrollee's medical records do support medications for gastrointestinal reflux disease are prescribed and symptoms can be worsened with Methotrexate. Azathioprine is supported as a disease modifying agent that is not as effective for the treatment of seronegative rheumatoid arthritis. Your prescriber has  indicated why all alternative drugs available on lower tiers to treat your condition would not be as effective. A physician reviewed your appeal and determined that the plan is required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis Emulsion 5% to treat 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.We requested documentation from your prescriber for your appeal. Your prescriber did not respond to the request. The record shows you were prescribed Restasis Emulsion for an unknown diagnosis. 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.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jynarque 90 tablet 30 milligram therapy package prescribed for polycystic kidney disease. 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 asked the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show the need for the medication. 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, we did not receive medical records to support why other drugs on the plans formulary would not work you. A physician reviewed your appeal and determined that the plan is not required to cover Jynarque.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Nucynta ER 100 milligram tablets prescribed for pain control. The Part D plan denied the request. 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.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine-Dextroamphetamine 10 milligram tablets prescribed for hypersomnia with obstructive sleep.apnea The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration 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 record shows you were prescribed Amphetamine-Dextroamphetamine for hypersomnia with obstructive sleep apnea. In review of the Medicare approved compendia, hypersomnia with obstructive sleep apnea is not a medically accepted indication for Amphetamine-Dextroamphetamine. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Amphetamine-Dextroamphetamine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets prescribed twice a day to treat small intestinal bacterial overgrowth with diarrhea.  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 prescriber initially provided the diagnosis of small intestinal bacterial overgrowth on 3/15/2021.  On 3/31/2021, the prescriber changed the diagnosis to irritable bowel syndrome. On 4/4/2021, the prescriber stated the diagnoses were small intestinal bacterial overgrowth and irritable bowel syndrome with diarrhea. The prescriber also stated that the enrollee has been on the requested drug since 10/29/2019. A request was submitted to the prescriber to clarify the diagnosis, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received. The use of the requested drug to treat small intestinal bacterial overgrowth with diarrhea 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 Calcitriol 1 microgram/milliliter solution per 30 days prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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 you filled prescriptions for Calcitriol at a network pharmacy. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, you did not provide proof of payment for the drug in the form of a receipt. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cephalexin 250 milligram/5 milliliter solution prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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 you filled a prescription for Cephalexin at a network pharmacy. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, you did not provide proof of payment for the drug in the form of a receipt. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxybutynin 5 milligram/5 milliliter syrup prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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 you filled prescriptions for Oxybutynin at a network pharmacy. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, you did not provide proof of payment for the drug in the form of a receipt. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sodium chloride 2.5 milliequivalent/milliliter solution prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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 you filled prescriptions for Sodium chloride at a network pharmacy. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, you did not provide proof of payment for the drug in the form of a receipt. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sodium polystyrene sulfonate powder prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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 you filled prescriptions for Sodium polystyrene sulfonate powder at a network pharmacy. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, you did not provide proof of payment for the drug in the form of a receipt. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin 40 milligrams tablet ER 12 hour abuse-deterrent prescribed 2 tablets per day for chronic pain syndrome and low back pain.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. 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. 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 Oxycontin 40 milligram tablet ER12 hour abuse-deterrent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xtampza 27 milligram extended-release oral capsule prescribed daily for chronic 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. We asked your prescriber to send us a supporting statement to show why the Xtampza is medically necessary.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. A physician reviewed your appeal and determined that the plan is not required to cover Xtampza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablets, 90 tablets for 90 days. 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. The documentation shows your doctor prescribed Corlanor to treat your unstable angina. 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 Corlanor.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Hydroxyzine Hydrochloride 10 milligram tablets prescribed for pruritis. 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.In the Reconsideration appeal the prescriber submitted additional information.  Your medical records show your doctor prescribed Hydroxyzine Hydrochloride to treat your pruritis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The prescriber answered yes to the question, Does the benefit of therapy with this prescribed medication outweigh the potential risks for this patient? The prescriber also indicates that the enrollee has been counseled to watch for sedation. The documents satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Hydroxyzine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Hyoscyamine Sulfate 0.125 milligram tablets prescribed for bloating due to irritable bowel syndrome. The Part D plan denied your request because the drug has not been approved by the Food and Drug Administration for the treatment of any condition. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.We determined that the plan is not required to cover Hyoscyamine Sulfate because the drug has not been approved by the Food and Drug Administration for the treatment of any condition. Drugs that have not been approved by the Food and Drug Administration 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 Gamunex-C 5 grams/50 milliliter injection solution prescribed for unspecified inflammatory polyneuropathies and autonomic ganglionopathy. 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 clinical note dated November 5, 2020 shows Gamunex was prescribed to treat unspecified inflammatory polyneuropathies and autonomic ganglionopathy. 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 Gamunex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xelpros Drops Emulsion 0.005% to treat glaucoma. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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

At issue is Tramadol Hydrochloride 50 milligram tablet prescribed for your condition. 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. Tramadol Hydrochloride is a generic drug on Tier 3 of the plans formulary. There are no generic 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 Taltz 80 milligram/milliliter auto-injector for psoriasis.   The requested drug is not on the plans formulary.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 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.