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

At issue is a request for coverage of Androderm 2 microgram per 24 hour transdermal patches. The Part D plan denied the request for coverage stating that the diagnosis of anemia in myelodysplastic syndrome was not a medically accepted indication for use of the drug.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 submitted at reconsideration indicates that the enrollee has a low testosterone level. The submitted documentation includes laboratory results obtained on June 16, 2021, which show a low testosterone level. The prescriber has not indicated whether the enrollee has primary, hypogonadotropic, or age-related/late-onset hypogonadism.  As outlined in the Medicare approved compendia, the safety and efficacy of testosterone replacement therapy in men with low testosterone concentrations related to aging have not been established. Furthermore, the Medicare approved compendia state that the diagnosis of male hypogonadism must be confirmed by measuring serum testosterone concentrations in the morning on at least two separate days. As noted previously, the record only includes serum testosterone levels from one day. Therefore, the diagnosis of male hypogonadism has not been confirmed. As such, 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 Linzess 72 microgram capsules. 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.Linzess is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. 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 Alphagan P 0.1% drops 45 milliliters per 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 information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this amount of the medication. We did not receive the documentation requested.At initial determination the diagnosis of glaucoma was given. However, no medical records have been submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia. The quantity limit requirements were not addressed because 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 Alphagan P, as the drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Heparin Sodium 20,000 units per milliliter solution. The Part D plan denied the request stating that the medication would be covered under Medicare Part B, as the enrollee was being treated for end stage renal disease and required dialysis.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. Drugs used for end stage renal disease enrollees receiving renal dialysis would be available under Medicare Part B, as these drugs are included in the Medicare Part B bundled payment to an end stage renal disease dialysis facility. Drugs covered under Medicare Part B are not available for coverage under Medicare Part D.We determined that the Medicare Part D plan is not required to cover the Heparin Sodium. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% ointment prescribed for chronic pain syndrome. 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 Lidocaine ointment for chronic pain syndrome. 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

At issue is Belbuca film 75 microgram prescribed twice a day for left elbow 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 you. A physician reviewed your appeal and determined that the plan is not required to cover Belbuca film.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sildenafil 20 milligram tablets prescribed for the treatment of pulmonary hypertension due to the presence of hypoplastic left heart syndrome. The Part D plan denied the request for coverage because the medication was being prescribed for a non-medically accepted indication.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.While the prescriber has noted that the enrollees condition indicates the presence of pulmonary artery hypertension, also referred to World Health Organization group 1 pulmonary hypertension, which is a medically accepted indication as outlined in the Medicare approved compendia, the submitted right heart catheterization results do not support the presence of pulmonary artery hypertension. 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 Azasan 75 milligram tablet prescribed for enteropathic arthritis and Crohns 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 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 and why other medications on the plan's formulary would not work for you. We did not receive the documentation requested. The documentation shows your doctor prescribed Azasan to treat your enteropathic arthritis and Crohns disease. 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 Azasan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Desvenlafaxine Succinate ER 50 milligram extended release 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 ER has been prescribed for the management of bipolar 1 disorder, most recent episode depressed; post-traumatic stress disorder; and dissociative identity disorder. 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

You requested Ondansetron 4 milligram disintegrating tablets prescribed for nausea and vomiting due to gastroparesis. 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 Ondansetron for nausea and vomiting due to gastroparesis. 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

At issue is Travatan Z 0.004% solution prescribed 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.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.. 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 a tiering exception request for Prolia 60 milligram/milliliter injection prescribed for the enrollees condition. 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.Prolia is a brand biologic on Tier 3 of the plans formulary. There are no brand biologics of the same type on the lower cost sharing tiers. Therefore, this biologic 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 Kineret 100 milligram/0.67 milliliter syringe prescribed for hidradenitis suppurativa. 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 Kineret for hidradenitis suppurativa. The Medicare approved compendia do not support the use of the biologic at issue for your conditions. As the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Arthrotec 50 milligram-200 microgram tablets. 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 include a supporting statement or medical records to support a covered diagnosis. A request for information was sent to your physician; however, no further documentation was received. As it cannot be determined 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 SM Mucus Relief Max Strength 1200 milligram tablets prescribed for post-nasal drip. 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 SM Mucus Relief because it is a nonprescription drug. Nonprescription or over-the-counter drugs 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 Benztropine Mesylate 1 milligram tablet prescribed twice daily for Alzheimers 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. The documentation shows your doctor prescribed Benztropine Mesylate to treat your Alzheimers disease. 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 Benztropine Mesylate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Promacta 50 milligram tablets prescribed for immune thrombocytopenic purpura. 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 documentation on file did not include a physician supporting statement. A request for information was sent to the prescriber; however, no further documentation was received. The documentation on file does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Afinitor 10 milligram tablet prescribed daily for endometrial 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 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 asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. The prescriber statement was received and we included it in our review. However, we did not received any clinical medical records.The documentation shows the doctor prescribed Afinitor to treat the enrollees endometrial cancer. However, the Medicare approved compendia do not support the use of this drug for this condition. 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.A physician reviewed your appeal and determined that the plan is not required to cover Afinitor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Horizant ER 300 milligram tablet prescribed for sedative, hypnotic or anxiolytic dependence withdrawal. 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 Horizant ER 300 milligram tablet prescribed for sedative, hypnotic or anxiolytic dependence withdrawal. 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 Horizant.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Motegrity 2 milligram oral tablet. 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.At initial determination your doctor stated Motegrity was prescribed to treat opioid-induced constipation. At redetermination, the documentation shows Motegrity was prescribed to treat constipation and diabetic delayed gastric emptying. 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 Motegrity. The formulary exception was not addressed because the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a prior authorization for Pregabalin 75 milligram capsules. 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 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

At issue is a prior authorization request for Uloric 40 milligram tablets prescribed for hyperuricemia in an enrollee with gout. 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 documentation on hand did not include a physician supporting statement. A request for information was sent to the prescriber. The prescriber submitted a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ibrance 75 milligram oral tablet. 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 information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. However, we did not receive the documentation.. No diagnosis was given at initial determination. In addition, no medical records have been submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia. As such, the prior authorization requirements were not addressed because 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 Ibrance.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine 10 microgram/hour patch prescribed for the enrollees condition. 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.Buprenorphine patch is a generic drug on Tier 4 of the plans formulary. A supporting statement and medical records were requested from your doctor. Your doctor submitted a supporting statement and medical records. The documentation on hand does not address why all alternative lower-tier medication on the plans formulary would not work for you. All drugs on lower tiers have not been tried. 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.