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

At issue is Vumerity DR 231 milligram capsules prescribed to treat multiple sclerosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Vumerity DR 231 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 500-milligram tablet to treat small intestinal bacterial overgrowth. 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 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.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 Methylphenidate Hydrochloride 5 milligram tablets prescribed for other conduct disorders, obsessive-compulsive behaviors, unspecified mental disorder due to known physiological condition, cerebral infarction, unspecified, other symptoms and signs involving cognitive functions and awareness, and tremor, unspecified. 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 Methylphenidate Hydrochloride to treat your other conduct disorders, obsessive-compulsive behaviors, unspecified mental disorder due to known physiological condition, cerebral infarction, unspecified, other symptoms and signs involving cognitive functions and awareness, and tremor, unspecified. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed your appeal and determined that the plan is not required to cover Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Livalo 2 milligram tablets prescribed for 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. This includes the case file from the plan and any information submitted at the reconsideration level.Livalo is not included in the plans formulary. During this review, a request was submitted to the prescriber to address the alternative drugs included in the plans formulary to treat the enrollees condition and to provide supporting medical records. The prescriber responded and medical records were received for review. However, the prescriber has not provided patient specific clinical rationale as to why all of the formulary alternatives included in the plan 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

You requested Benzonatate 100 milligram capsule prescribed every eight hours as needed for the symptomatic relief of a cough. The Part D plan did not make a decision.We performed and independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level.We determined that the plan is not required to cover Benzonatate because it was for the symptomatic relief of coughs and colds. Drugs prescribed for symptomatic relief of cough and colds 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 a formulary exception request for Diclofenac Sodium 3% gel prescribed to apply 2 grams to affected area(s), twice daily, as needed for pain to treat other postherpetic nervous system involvement. 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 documentation shows your doctor prescribed Diclofenac Sodium 3% gel to treat other postherpetic nervous system involvement. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not support the use of this drug for your condition.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 a request for coverage of Lidocaine 5% ointment. 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% ointment has been prescribed for chemotherapy-induced neuropathy, osteoarthritis of both knees, and as a numbing agent prior to getting injections in the knees. 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 your appeal and determined that the plan is not required to cover the Lidocaine 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram capsule prescribed for lack of appetite secondary to breast 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. The documentation shows your doctor prescribed Dronabinol to treat your lack of appetite secondary to breast cancer. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed your appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Contrave 8-90 milligram tablet prescribed for severe morbid obesity due to excess calories. 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 Contrave because drugs used to treat weight gain (promote weight loss) 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: Favorable

At issue is Mavenclad 20 milligram tablets prescribed for multiple sclerosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your prescriber submitted medical records supporting you have tried and failed Glatiramer Acetate and Interferon Beta-1b. Your plan requires you have tried and failed two available formulary alternatives prior to the use of a non-formulary medication. In this case, the medical records support the formulary exception criteria. A physician reviewed your appeal and determined that the plan is required to cover Mavenclad.
Appeal type: Prescription Drug
Decision: Favorable

You requested Lorazepam 1 milligram tablets prescribed for panic disorder and anxiety. 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.The submitted documentation indicates your doctor prescribed Lorazepam for panic disorder and anxiety. The Medicare approved compendia support the use of the drug at issue for your condition. In addition, your doctor submitted a supporting statement to indicate you have been stable on the medication since 2017.A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rexulti 2 milligram tablets prescribed for major depressive disorder, recurrent. 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 reviewed the enrollment data available. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plan requires that there be a diagnosis of schizophrenia or major depressive disorder and documented inadequate or intolerance to aripiprazole and at least one other atypical antipsychotic. Your prescribed states that your diagnosis is major depressive disorder and that you have tried and failed Abilify and Zyprexa. We requested medical records to support the other medications tried and to show they were ineffective or caused side effects. We did not receive a response. Therefore, the pre-authorization requirements were not satisfied.A physician reviewed your appeal and determined that the plan is not required to cover Rexulti.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligram per milliliter syringe prescribed for mixed hyperlipidemia. 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. Repatha syringe is a biological product drug on Tier 3 of the plans formulary. There are no biological product 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

You requested reimbursement for oxycodone/acetaminophen 7.5/325 milligram tablets prescribed for an unknown diagnosis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. There is insufficient documentation to approve your request. Without medical records, we cannot determine if the medication is medically necessary and reimbursable. A physician reviewed your appeal and determined that the plan is not required to reimburse the oxycodone/acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium Gel 1% prescribed for degeneration of thoracic intervertebral disc, muscle pain unspecified, thoracic back pain, and pain in lower right leg. 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 drug, at the strength requested, is an over-the-counter medication. Non-prescription drugs are excluded from Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium Gel 1%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Motegrity 2 milligram tablet prescribed for chronic idiopathic constipation.   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.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: Unfavorable

At issue is Auryxia 1 gram tablets prescribed for control of serum phosphorus in an enrollee with chronic kidney disease not on dialysis. 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. Your prescriber indicated that Auryxia is prescribed to for control of serum phosphorus in an enrollee with chronic kidney disease not on dialysis. 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 Auryxia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dicyclomine Hydrochloride 20 milligram tablets prescribed for unspecified abdominal 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. Your prescriber indicated that Dicyclomine Hydrochloride is prescribed to treat unspecified abdominal 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 Dicyclomine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Movantik 25 milligram tablet prescribed for drug-induced constipation. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.Your plan has step therapy requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not include medical records to 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 Movantik.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium Gel 1% prescribed for arthritis in the elbow. 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. Diclofenac Sodium Gel 1% is available over-the-counter. Non-prescription drugs are excluded from Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium Gel 1%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Praluent 75 milligram pen-injector prescribed for atherosclerotic cardiovascular disease and dyslipidemia. 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. We received the documentation and included it in our review.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 prescriber did not include 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.A physician reviewed your appeal and determined that the plan is not required to cover Praluent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 300 milligram capsule prescribed daily 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. The documentation shows your doctor prescribed Gabapentin to treat your restless leg syndrome. However, the Medicare approved compendia do not support the use of this form of the drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Gabapentin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of GaviLax 17 grams per dose powder prescribed for chronic constipation, history of sigmoid colectomy, and history of bowel obstruction. 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 records submitted at the reconsideration level. GaviLax does not meet the definition of a Part D drug, as this drug is available without a prescription. Nonprescription drugs are excluded from the Part D benefit. 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 a request for coverage of Desvenlafaxine Succinate 100 milligram tablets. 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 Desvenlafaxine Succinate has been prescribed for schizoaffective disorder, depressive type. 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 the Desvenlafaxine Succinate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone Gel 1.62% prescribed for late-onset (age-related) 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 information submitted at the reconsideration level. Your prescriber indicated that Testosterone Gel 1.62% is prescribed for late-onset (age-related) hypogonadism. The Medicare approved compendia indicates the safety and efficacy of testosterone replacement therapy for men with late-onset hypogonadism have not been established. Primary hypogonadism was not supported in the medical records submitted.  A physician reviewed your appeal and determined that the plan is not required to cover Testosterone Gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gamunex-C 200 grams intravenously prescribed daily for other specified abnormal immunological findings in serum. 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 Gamunex-C to treat the enrollees other specified abnormal immunological findings in serum. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Gamunex-C.