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

At issue is a formulary exception for Lumakras 120 milligram tablets prescribed for pancreatic cancer. 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 the prescriber ordered Lumakras to treat the Enrollees pancreatic cancer. The Medicare approved compendia do not support the use of the drug at issue for your conditions. There are no Medicare approved journal articles to support the use of Lumakras for the Enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Xeljanz 5 milligram tablets prescribed for rheumatoid arthritis. 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 Xeljanz. Of note, you requested a quantity in excess of the plans quantity limit. As the drug cannot be approved, a quantity limit exception cannot be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Flector 1.3% 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 documentation indicates that Flector patches have been prescribed for severe acute low back pain and bilateral knee osteoarthritis. 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 conditions. Therefore, the drug is being prescribed for non-medically accepted indications 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 Mvasi 400 milligram/16-milliliter solution prescribed unknown frequency for stage 4 colon cancer. 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 Mvasi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Xifaxan 200 milligram tablets, 180 tablets for a 30-day supply. 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 documentation indicates that Xifaxan 200 milligram tablets have been prescribed for the treatment of unspecified hepatic failure without coma. However, the Medicare approved compendia do not contain any citations to support the use of the Xifaxan 200 milligram tablets 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 Diclofenac Sodium 1% transdermal gel prescribed two grams four times daily for shoulder pain due to a rotator cuff tear, bursitits, and tendinopathy. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we reviewed the appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.The doctor prescribed Diclofenac Sodium 1% transdermal gel to treat the enrollees shoulder pain due to a rotator cuff tear, bursitits, and tendinopathy. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed this appeal and determined that the plan is not required to cover Diclofenac Sodium 1% transdermal gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine 5% adhesive 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 documentation indicates that Lidocaine 5% patches have been prescribed for the tinnitus of the left ear. 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

You requested Promacta 50 milligram tablet prescribed for chronic lymphocytic leukemia and other secondary thrombocytopenia. 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 Promacta to treat your  chronic lymphocytic leukemia and other secondary thrombocytopenia. 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 Promacta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 100 milligram capsule prescribed 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. This includes the case file from the plan, and any records submitted at the reconsideration level. Your prescriber indicates you have failed Gabapentin and Rasagiline and have done very well on the generic Pregabalin for your chronic pain. However, 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 Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Adcirca 20 milligram tablets prescribed as directed for pulmonary arterial 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. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Adcirca.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a prior authorization request for Tafinlar 75 milligram capsules prescribed for papillary thyroid cancer. 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. The enrollee satisfies the plan's coverage criteria. The submitted documentation indicates the enrollee has a diagnosis of papillary thyroid cancer with a positive BRAF mutation. The drug at issue is to be used in conjunction with Mekinist. The Medicare approved compendium supports the drug at issue has an orphan drug designation for Tafinlar to be used in conjunction with Mekinist in enrollees with anaplastic thyroid cancer with a BRAF V600 mutation.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Esbriet prescribed for idiopathic pulmonary fibrosis. 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. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Your prescriber submitted documents supporting the diagnosis of idiopathic pulmonary fibrosis. However, the documentation provided does not support a baseline forced vital capacity of at least 50% and a percent predicted diffusing capacity of the lungs of carbon monoxide of at least 30%. The records do not support you have satisfied the plan's prior authorization requirements. A physician reviewed your appeal and determined that the plan is not required to cover Esbriet. 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 Hydrochloride Urethral/Mucosal 2% topical gel. 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 medical records to support a covered 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

At issue is Testosterone 1.62% gel prescribed for male hypogonadism. 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. Your medical records show your doctor prescribed Testosterone 1.62% gel prescribed for male hypogonadism. 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 Testosterone. 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 Lynparza 150 milligram tablet prescribed for metastatic cholangiocarcinoma. 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. Your prescriber indicates they prescribed Lynparza 150 milligram tablet for metastatic cholangiocarcinoma. 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 Lynparza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Diclofenac Sodium 1% topical gel. 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 indicates that Diclofenac Sodium gel has been prescribed for the treatment of inflammation due to chronic 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 the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablets prescribed for anticoagulation therapy due to the presence of paroxysmal atrial fibrillation and recent cerebrovascular accident. 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. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the enrollees condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rexulti 0.5 milligram tablet prescribed for major depressive 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 records submitted at the reconsideration level. Your medical records show your doctor prescribed Rexulti to treat your major depressive disorder. 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 Rexulti. 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 Zofran 4 milligram tablet prescribed for nausea and vomiting due to kidney injury/urinary tract infection. 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. Your prescriber indicates that Zofran 4 milligram tablet is prescribed to treat nausea and vomiting due to kidney injury/urinary tract infection. 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 Zofran.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig 140 milligrams per milliliter solution auto-injector prescribed to treat migraines. 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 Aimovig 140 milligrams per milliliter solution auto-injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benztropine Mesylate 1 milligram tablet prescribed twice daily for schizophrenia and severe major depressive disorder. 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 Benztropine Mesylate to treat the enrollees schizophrenia and severe major depressive disorder. At reconsideration a diagnosis of Parkinsonism was given. However, the medical records provided by the prescriber do not support this diagnosis. The Medicare approved compendia do not support the use of this drug for the enrollees conditions. A physician reviewed your appeal and determined that the plan is not required to cover Benztropine Mesylate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 1% gel prescribed for joint 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 requested additional information from your provider. Your physician did not respond with the necessary information. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plans prior authorization requirements were not met. A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Humira 40 milligram per 0.4 milliliter subcutaneous injection pen. 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 indicates that Humira has been prescribed for the treatment of cutaneous and pulmonary sarcoidosis. 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 conditions. Therefore, the drug is being prescribed for non-medically accepted indications 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 Lidocaine Patch 5% prescribed for unspecified rotator cuff tear or rupture of the right shoulder, shoulder pain, and primary generalized osteoarthritis. 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 records submitted indicate you have had bilateral shoulder pain for 3 years and an imaging test shows tendinosis, osteoarthrosis, and a non-displaced tear of the left shoulder area. 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 Patch 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 4 milligram disintegrating tablets prescribed for nausea and vomiting. 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 medical records to support a covered 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

At issue is Itraconazole 100 milligram capsule prescribed two capsules twice daily for unspecified zygomycosis. 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 shows the doctor prescribed Itraconazole to treat the enrollees unspecified zygomycosis. However, the Medicare approved compendia do not support the use of this drug for this unspecified condition. A physician reviewed the appeal and determined that the plan is not required to cover Itraconazole.