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

At issue is coverage for Buprenorphine Hydrochloride 8 milligram sublingual tablets, 120 tablets for 30 days. The Part D plan denied the request for coverage because the prior authorization requirements were not met. Additionally, the amount requested exceeded the plans quantity limits.  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 Buprenorphine Hydrochloride sublingual tablets have been prescribed for chronic pain due to multiple conditions, including fibromyalgia, rheumatoid arthritis, end stage renal disease, vasculitis, and diffuse connective tissue disease. However, the Medicare approved compendia do not contain any citations to support the use of Buprenorphine Hydrochloride sublingual tablets, 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. Since the drug is not eligible for coverage under Medicare Part D, the plans prior authorization requirements and quantity limits are not applicable to this review. A physician reviewed your appeal and determined that the plan is not required to cover the Buprenorphine Hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz 5 milligram tablets prescribed as directed for rheumatoid arthritis. The Part D plan denied your request because the documentation did not support an off-formulary 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 also researched Medicare systems and reviewed the enrollment data available. 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 the Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Oxycodone ER 20 milligram tablets prescribed for chronic pain. 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 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.Oxycodone ER is not included in the plans formulary. At reconsideration, the prescriber has stated that the enrollee has taken the formulary alternative, Xtampza ER, in the past and it caused nausea and vomiting. However, medical records to validate this statement have not been submitted for review. 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 Gammaplex 10% prescribed for non-familial hypogammaglobulinemia. 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. 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 Gammaplex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 80 milligram tablet prescribed daily at bedtime for bipolar disorder, 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 records submitted at the reconsideration level. The medical records show you prescribed Latuda 80 milligram tablet to treat the enrollees bipolar disorder, unspecified. The medical records submitted do not adequately support the enrollees diagnosis of depressive episodes. 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 Latuda 80 milligrams tablet. 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 Ustekinumab 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.The submitted documentation indicates your doctor prescribed Ustekinumab for hidradenitis suppurativa. The Medicare approved compendia do not support the use of this biologic for your condition. As it cannot be determined that the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 1% Gel to treat shoulder pain due to osteoarthritis. 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.At reconsideration, an additional diagnosis, W19.XXXD  Unspecified fall, was provided but without supporting medical records. The use of the requested drug to treat the provided diagnoses 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 these conditions. 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 Cyanocobalamin 1000 microgram/1 milliliter intramuscular solution prescribed for vitamin b12 defiency. 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. According to Medicare rules, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Cyanocobalamin. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol 180 milligram tablet prescribed for hyperlipidemia. The Part D plan denied your request because the documentation did not support an off-formulary 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. 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 Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Voriconazole 200-milligram tablet to treat acute myeloblastic leukemia, not having achieved remission. 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 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 Tobramycin 300 milligram/5 milliliter nebulizer solution prescribed for pneumonia due to pseudomonas. The Part D plan denied the 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 drug at issue is for use with a nebulizer in the enrollees home. This is eligible for coverage under Part B. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Tobramycin nebulizer solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Octreotide Acetate 1000 microgram/milliliter solution prescribed as directed for perforation of intestine non-traumatic, and explosive diarrhea due to short bowel 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Octreotide Acetate to treat your perforation of intestine non-traumatic, and explosive diarrhea due to short bowel syndrome. However, the Medicare approved compendia do not support the use of this drug for your conditions. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and  determined that the plan is not required to cover the Octreotide Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Dronabinol 2.5 milligram capsules. 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 Dronabinol has been prescribed for dementia-related abnormal weight loss and adult failure to thrive. However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram/milliliter auto injector prescribed for pure hypercholesterolemia and atherosclerotic heart disease of native coronary artery without angina pectoris. 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 Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 145 microgram capsule prescribed for constipation related to Parkinson's disease. 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 Nuedexta 20 milligram-10 milligram capsules prescribed for epilepsy. 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 Nuedexta for epilepsy and indicated you had a prolonged QT interval. Your doctor submitted a supporting statement that indicated a one-time prolonged QT interval and indicated the diagnosis should be pseudobulbar affect. However, the submitted progress notes do not support a diagnosis of pseudobulbar affect and indicate you are taking the drug for anxiety and seizure 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: Unfavorable

You requested Clonazepam 0.5-milligram oral tablet prescribed for panic disorder. The Part D plan denied your request for a quantity limit exception. We received a reconsideration 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 required to cover Clonazepam 0.5-milligram oral tablet prescribed daily. The Medicare approved compendia supports the dosage and frequency. Therefore, the plan is required to cover the requested quantity of 0.5-milligram oral tablet daily for the noted condition.A physician reviewed your appeal and determined that the plan is required to cover the Clonazepam, as the drug meets the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 200 milligram tablets prescribe to treat fatigue due to multiple sclerosis. 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. DrugDex, a Medicare approved compendia states:  In a 9-week, phase 2, single-blind, 2-center pilot study (n=72), 2 weeks of modafinil 200 mg daily significantly improved Fatigue Severity Scale (FSS) scores compared with placebo in patients with relapsing-remitting or progressive multiple sclerosis.  Therefore the requested drug is being used for a medically accepted indication. However, the documentation does not satisfy the plans coverage criteria that are approved by Medicare.  The prescriber has indicated that the diagnosis is fatigue due to multiple sclerosis. An exception to the plans coverage criteria cannot be granted. 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 Zolpidem 10 milligram tablets prescribed to treat insomnia. 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 submitted documentation includes prescriber documentation that supports the prior authorization requirement of a noted contraindication to Doxepin. However, the prescriber did not acknowledge the benefit of therapy with the prescription medication outweighs the potential risks for the enrollee. The prior authorization requirements were not met. A physician reviewed your appeal and determined that the plan is not required to cover Zolpidem.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Exelon 9.5-milligrams/24-hour Patch (Rivastigmine) to treat dementia with Lewy bodies. 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.Medical records establishing the diagnosis, and use of this drug since 2017 with improvement are provided. DrugDex, a Medicare approved compendia states:  Rivastigmine was effective in treating dementia with Lewy bodies in 2 studies involving a total of 149 patients.  Therefore, the requested drug is being used for a medically accepted indication. Additionally, also in Micromedex, Rivastigmine is the only drug for which dementia with Lewy bodies is a medically accepted indication. All other formulary drugs do not list dementia with Lewy bodies as a medically accepted indication. Therefore, a formulary exception is granted.Our physician reviewer's opinion is that formulary exception criteria are met, and coverage by the plan is required.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Promethazine Hydrochloride 25 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 Promethazine Hydrochloride has been prescribed for nausea secondary to metastatic uterine cancer. However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, 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 Promethazine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 5 milligram tablets prescribed for muscle spasms associated with chronic back and neck pain. 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 Cyclobenzaprine Hydrochloride for muscle spasms associated with chronic back and neck pain. 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 Diovan HCT 320-25 milligram tablets prescribed as directed for hypertension. The Part D plan denied your request because the documentation did not support an off-formulary 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 also researched Medicare systems and reviewed the enrollment data available. 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 the Diovan HCT.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for chronic shoulder pain from a supraspinatus tendon tear. 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 Lidocaine 5% patch was prescribed to treat chronic shoulder pain from a supraspinatus tendon tear. 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Mayzent 0.25 milligram tablets prescribed for relapsing-remitting multiple sclerosis 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.Mayzent is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan would likely not be as effective as the requested drug for this condition, 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.