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

At issue is a formulary exception request for Repatha Sureclick 140 milligram/milliliter pen injector prescribed for mixed 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. A physician reviewed the appeal and determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone gel 50 milligram/5 gram (1%). 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 plan has agreed to provide the requested drug at a cost sharing level assigned to Tier 3. There are no drugs of the same type on the lower cost sharing tiers. Therefore, a tier exception cannot be considered to Tier 1 as requested.A physician reviewed your appeal and determined that the plan is not required to grant the request for a lower tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsule prescribed for non-24 hour sleep-wake 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 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 asked the prescriber to send us information regarding the enrollee's condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested.The medical records show Hetlioz 20 milligram capsule was prescribed for non-24 hour sleep-wake disorder. The 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 Hetlioz. 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 Hetlioz 20 milligram capsule prescribed for non-24 hour sleep-wake 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 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 asked the prescriber to send us information regarding the enrollee's condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested.The medical records show Hetlioz 20 milligram capsule was prescribed to treat non-24 hour sleep-wake disorder. The 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 Hetlioz. 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 Tadalafil 5 milligram tablet prescribed daily for primary pulmonary hypertension. 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.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. A reply from the prescriber was not received.  Tadalafil 5 milligram tablet is prescribed to treat the enrollees primary pulmonary hypertension. However, the Medicare approved compendia do not support the use of this dose of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Tadalafil 5 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 250 milligram capsules prescribed for polymyositis. 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 submitted documentation indicates the prescriber ordered Mycophenolate Mofetil for polymyositis. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 Travatan Z 0.004% Ophthalmic Drops 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.This medication is not on your plan's list of medications. The prescriber has not given a clear and valid medical reason why all medications required by the plan, on that list, did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. Therefore, an exception to the plans formulary coverage criteria is not supported. 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 Odactra 12-SQ-HDM sublingual tablet prescribed daily for allergic rhinitis due to house dust mites. 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 records 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. We received the documentation and included it in our review.The doctor prescribed Odactra sublingual tablet to treat the enrollees allergic rhinitis due to house dust mites. The 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 the appeal and determined that the plan is not required to cover Odactra sublingual tablets. 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 Harvoni 400/90-milligram tablet to treat chronic hepatitis C, Genotype 1a, with HCV RNA viral without cirrhosis. 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 documentation provided addressed the plans coverage criteria, and those criteria were not satisfied. 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 Hetlioz 20 milligram capsules prescribed for non-24 hour sleep-wake 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 records 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 the enrollee needs this medication. No documentation was received.The documentation submitted indicates the prescriber ordered Hetlioz for non-24 hour sleep-wake disorder. The 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 the appeal and determined that the plan is not required to cover Hetlioz. 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 Corlanor 5 milligram tablet prescribed for postural orthostatic tachycardia 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 Corlanor is prescribed to treat postural orthostatic tachycardia syndrome. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 40-milligram capsule. At initial determination and redetermination the diagnosis of other specified behavioral and emotional disorder with onset usually occurring in childhood and adolescence was given. 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.At reconsideration a diagnosis of attention deficit hyperactivity disorder was given. No medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for medically accepted indications. 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

At initial determination and redetermination, Gralise ER 600 milligram tablet prescribed twice daily for polyneuropathy, fibromyalgia, and rheumatoid arthritis.. 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. At reconsideration, a diagnosis of post herpetic neuralgia was introduced, but was not supported in the medical record as the reason this drug was prescribed. 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, as ordered, is not being used for a medically accepted indication. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules. The requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the plan is not required to cover Gralise ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone-Acetaminophen 7.5-300 milligram tablet 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 information submitted at the reconsideration level. We asked the prescriber to send us information regarding  the enrollee's condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee.  .  A reply from the prescriber was not received.  In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, we did not receive medical records to support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Hydrocodone-Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of OxyContin ER 20 milligram extended release tablets prescribed for chronic pain syndrome. 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. It is noted that, at reconsideration, the prescriber has also requested reimbursement to the enrollee for OxyContin tablets purchased on June 30, 2021.OxyContin ER is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives that are included in the plan to treat the enrollees 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. As such, the plan is not required to cover or provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsule prescribed for circadian rhythm sleep disorder, free running type. 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 establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, medical records supporting that medically accepted indication are required. These records were requested from the prescriber, and we did not receive information that could answer these medical necessity issues.  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 Hetlioz.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Clobazam 10-milligram tablet 120-tablets/30-days to treat localization-related epilepsy with complex partial seizures with intractable epilepsy. 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 record shows the physician prescribed Clobazam 10-milligram tablet 120-tablets/30-days to treat your condition. We asked the prescriber if you are unable to take one 20-milligram tablet twice daily instead of two 10-milligram tablets twice daily. Your physician replied saying that that the dosage prescribed is for titrating the drug to avoid adverse harmful side effects. The use of Clobazam for your diagnosis of complex partial seizures with intractable epilepsy as stated by the compendium, Lexicomp, allows coverage. Clobazam has demonstrated broad anticonvulsant activity and has been used extensively in adults and pediatric patients with a wide range of other seizure disorders, which have sometimes been refractory, including partial, generalized, and myoclonic seizures. In several randomized controlled trials, Clobazam, when used as adjunctive therapy, reduced the frequency of refractory seizures and was particularly useful in patients with partial onset seizures. The plan limits the amount of Clobazam 10-milligram tablets to 60-tablets/30-days. The prescriber has indicated that the number of doses of the requested drug are to allow titration of the drug to avoid adverse harmful side effects to the beneficiary. Therefore, an exception to the plans coverage criteria is supported. Our physician reviewer's opinion is that quantity limit criteria are met. The plan is to required to cover Clobazam, 10-milligram tablets, 120-tablets/30-days.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tramadol Hydrochloride extended-release 24-hour 200 milligram tablets prescribed to treat chronic knee 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 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.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 the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Tramadol Hydrochloride extended-release 24-hour 200 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Asenapine 10 milligram tablets prescribed for major depressive disorder. 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 submitted documentation indicates the prescriber ordered Asenapine for major depressive disorder. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 Estradiol 10 microgram vaginal tablets prescribed for recurrent urinary tract infection. The Part D plan denied the request because the drug was not on the plans formulary.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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. However, we did not receive the documentation. The documentation shows Estradiol was prescribed to treat recurrent urinary tract infection. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. Therefore, an exception for a drug not on the plans formulary will not be addressed.A physician reviewed your appeal and determined that the plan is not required to cover Estradiol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20-milligram capsule to treat circadian rhythm sleep disorder, free running type (Non-24). The 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.To support this diagnosis, the prescriber provided no medical records.  The submitted prior authorization request form was only partially completed.  The documentation provided does not satisfy the plans coverage criteria.   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 Forteo 620-micrograms/2.48-milliliters to treat post-menopausal osteoporosis. 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 documentation does not satisfy the plans coverage criteria. The treatment of the enrollees condition began in July 2019. The 24-months of allowed treatment in the enrollees lifetime with Forteo had transpired by the time of this request. As such, 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.