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

You requested coverage for Ofev 100 milligrams prescribed for chronic fibrosing interstitial lung disease with progressive phenotype. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Ofev for chronic fibrosing interstitial lung disease with progressive phenotype. In review of the Medicare approved compendia, chronic fibrosing interstitial lung disease with progressive phenotype falls under the category of idiopathic pulmonary fibrosis that is a medically accepted indication for Ofev. Therefore, it does meet the definition of a Part D drug. The plan is required to cover the Ofev at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz Extended Release, 11 milligrams prescribed one tablet daily for rheumatoid arthritis with rheumatoid factor. The Part D plan denied your request for a formulary exception because the physician has not tried you on at least two other covered drugs for your condition. We received an expedited reconsideration request.We performed an independent and de novo review. 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.The record shows that your doctor prescribed Xeljanz Extended Release to treat your rheumatoid arthritis with rheumatoid factor. The Medicare approved compendia support the use of this drug to treat your condition. Your doctor submitted a prescriber statement indicating that you tried methotrexate, which is on your formulary. The methotrexate did not improve your condition. However, the plan formulary includes other drugs that could be used to treat your condition. Your medical records do not show that another alternative drug on the plan formulary has been tried or why you cannot take that drug(s). A physician reviewed your appeal and determined that the plan is not required to grant a formulary exception for Xeljanz Extended Release because at least two other covered drugs have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Butalbital/Acetaminophen/Caffeine 50-325-40 milligrams prescribed every six hours as needed for chronic non-intractable headaches and left occipital neuralgia. The Part D plan denied a cumulative acetaminophen dose exceeding 4 grams per day limit exception because the drug was not prescribed for a medically accepted indication. We received an expedited 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.Your medical records show your doctor prescribed Butalbital/Acetaminophen/Caffeine 50-325-40 milligrams to treat the enrollees chronic non-intractable headaches and left occipital neuralgia. However, the Medicare approved compendia do not support the use of this drug for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Butalbital/Acetaminophen/Caffeine 50-325-40 milligrams. We cannot considered a cumulative acetaminophen dose exceeding 4 grams per day limit exception for a drug the Part D plan cannot cover.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Arikayce 590 milligrams per 8.5 milliliters, suspension for inhalation via nebulizer prescribed for treatment of Mycobacterium abscessus. The Part D plan denied the request because the enrollees condition was not a medically accepted indication by Medicare approved compendia. We received a request to reconsider the appeal.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 also researched Medicare systems and reviewed the enrollment data available.The medical record shows Arikayce 590 milligrams per 8.5 milliliters has been prescribed to treat the enrollees condition. The medical record also shows the enrollee was previously treated with Arikayce for Mycobacterium avium complex and a culture was still positive for Mycobacteium abscessus. However, the Medicare approved compendia do not support the use of this drug for Mycobacteium abscessus.A physician reviewed your appeal and determined that the plan is not required to cover Arikayce 590 milligrams per 8.5 milliliters, suspension for inhalation via nebulizer, because the enrollees condition is not medically approved indication per Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Verzenio 150 milligrams, tablets prescribed to treat metastatic dedifferentiated liposarcoma. The Part D plan denied the request because the enrollees condition was not a medically accepted indication by Medicare approved compendia. We received a request to reconsider the appeal.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 also researched Medicare systems and reviewed the enrollment data available.The medical record shows Verzenio 150 milligrams has been prescribed to treat the enrollees condition. However, the Medicare approved compendia do not support the use of this drug for metastatic dedifferentiated liposarcoma. A physician reviewed your appeal and determined that the plan is not required to cover Verzenio 150 milligrams, because the enrollees condition is not a medically approved indication per Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate 500 milligrams prescribed twice a day for treatment of pemphigus vulgaris. The Part D plan denied the request because the enrollees condition was not a medically accepted indication by Medicare approved compendia. We received a request to reconsider the appeal.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 also researched Medicare systems and reviewed the enrollment data available.The medical record shows Mycophenolate 500 milligrams has been prescribed to treat the enrollees condition. However, the Medicare approved compendia do not support the use of this drug for pemphigus vulgaris.A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate 500 milligrams, because the enrollees condition is not a medically approved indication per Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine HCl 8 milligram sublingual tablets prescribed for chronic pain syndrome. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited 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. The prescriber initially provided the diagnosis of chronic pain syndrome. On January 19, 2021, the prescriber stated the diagnosis was not opioid use disorder. In the reconsideration appeal, the prescriber changed the diagnosis to from chronic pain syndrome to opioid related disorder. Records were requested to support the diagnosis. However, the requested records were not provided. The records submitted do not support a diagnosis of opioid use disorder or dependence. The use of the requested drug to treat chronic pain syndrome 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 the enrollees condition.  Therefore, 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 Buprenorphine sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch, 90 patches for 15 days prescribed six times daily for post-herpetic nervous system involvement. The Part D plan denied your request because the quantity prescribed exceeded the quantity limit for the drug. We received an expedited 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 also researched Medicare systems and reviewed the enrollment data available.The prescriber statement shows your doctor prescribed Lidocaine patches to treat your post-herpetic nervous system involvement. The current quantity covered by your plan for Lidocaine 5% patch is 90 patches every 30 days. Additional records were requested to support that the quantity of the drug allowed by your plan was not effective or was not likely to be effective for the treatment of your condition. However, the requested records were not submitted. Your plan requires that quantity limit criteria must be met. The requested quantity for the drug is above the quantity limit. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover the requested quantity of Lidocaine 5%, 90 patches per 15 days. A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine 5% patch, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is IPRATROPIUM BROMIDE via a nebulizer to treat shortness of breath and cough in an enrollee with Amyotrophic Lateral Sclerosis.  The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited 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.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 the enrollees condition.  Also, a drug prescribed for a Part D eligible individual cannot be considered a covered Part D drug if payment for the drug is available under Medicare Part A or B for that individual. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine and Prilocaine 2.5/2.5% cream prescribed for paresthesia of skin. The Part D plan denied your request because the diagnosis is not a medically accepted indication. We received an expedited 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. The prescribers statement supports your physician prescribed the Lidocaine and Prilocaine cream to treat your skin paresthesia. 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 the Lidocaine and Prilocaine cream. This medication has not been medically approved for your diagnosis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 250 milligram tablets prescribed for the diagnosis of major depressive disorder, recurrent severe without psychosis. The Part D plan denied your request because this drug is not medically accepted per Medicare rules for this condition. We received an expedited reconsideration 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 also researched Medicare regulations and Medicare approved compendia. The prescriber submitted a statement that indicates the enrollee has recurrent depression and states there is a large evidence base supporting the use of Modafinil for this disorder. However, Medicare approved compendia do not support the use of this drug for depression. Medicare requires that the drug must be prescribed for a medically accepted indication that is approved by the FDA or supported by one or more citations in Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Venclexta 100 milligram tablets prescribed for the diagnosis of myelodysplastic syndrome, unspecified. The Part D plan denied your request because this drug is not medically accepted per Medicare rules for this condition. We received an expedited reconsideration 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 also researched Medicare regulations and Medicare approved compendia. The prescriber submitted a statement that states the enrollee requires this treatment for myelodysplastic syndrome and indicated the medication was supported for this condition in the American Journal of Hematology and at a study presented by the American Society of Hematology. However, Medicare approved compendia do not support the use of this drug for myelodysplastic syndrome. Medicare requires that the drug must be prescribed for a medically accepted indication that is approved by the FDA or supported by one or more citations in Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Venclexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tremfya to treat plaque psoriasis. 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 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 enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan would likely cause harm or not be as effective for the enrollee as the requested drug.  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 Dupixent, 300 milligram per 2 milliliter auto injector for the treatment of atopic dermatitis. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited 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. A physician reviewed your appeal and determined that the plan is not required to cover the Dupixent as an off-formulary exception.Your doctor submitted a supporting statement and medical records. The medical records show that Dupixent was prescribed to treat your atopic dermatitis. The Medicare approved compendia support the use of the requested drug for your condition.However, the records do not show why you cannot take other drugs on your plans formulary for your condition. While your doctor stated you did try some other medications for your condition, there are other drugs listed on your plans formulary to treat your condition that have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

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 also researched Medicare regulations and Medicare approved compendia. The prescriber submitted a statement that indicates the enrollee has multiple sclerosis and takes this medication for fatigue related to her condition. However, Medicare approved compendia do not support the use of this drug for multiple sclerosis. Medicare requires that the drug must be prescribed for a medically accepted indication that is approved by the FDA or supported by one or more citations in Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Amphetamine-Dextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hetlioz 20 milligrams prescribed daily for insomnia due to mental disorder. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received an expedited 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 also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Hetlioz 20 milligrams daily to treat your insomnia due to mental disorder. However, the Medicare approved compendia do not support the use of this drug for your condition. 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 Hetlioz 20 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pregabalin 25 mg prescribed daily for neuropathy. The Part D plan denied your request because the plans prior authorization criteria was not met. We received an expedited 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 also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Pregabalin to treat neuropathy. The Medicare approved compendia do support the use of this drug for your condition. The physicians letter indicates that you have been stable on this medication and that you have tried Gabapentin which did not provide adequate relief of your symptoms. The physician also indicated that Gabapentin was tried and failed with a previous prescriber. However, medical records were requested to support an inadequate response, intolerance, or contraindication to Gabapentin. The records received show conflicting information and the requested medical records were not provided. The plan requires that prior authorization criteria are met. The records do not support that prior authorization criteria are met for the drug.    A physician reviewed your appeal and has determined that the plan is not required to cover Pregabalin because the prior authorization criteria were not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolastin 1, 000 milligrams, injection, for treatment of alpha-1 antitrypsin deficiency. The Part D plan denied coverage because Gamunex-C prior authorization guidelines criteria was not met. We received a request to reconsider this appeal.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. We also researched Medicare systems and reviewed the enrollment data available.The medical record shows Prolastin-C has been prescribed as an augmentation treatment for the enrollees condition. The medical record also shows the enrollee was initially diagnosed with chronic obstructive pulmonary disease four years ago and a work-up revealed alpha-1 antitrypsin deficiency. The documentation received includes a completed prior authorization form. However, the clinical information provided did not meet the prior authorization criteria for Prolastin-C.A physician reviewed your appeal and determined that the plan is not required to cover Prolastin 1,000 milligrams, injection, because the prior authorization criteria for the drug has not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Strensiq 80 milligrams/0.8 milliliters injection prescribed for juvenile-onset hypophosphatasia. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization requirements be met before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited 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 records submitted at the reconsideration level. We asked the prescriber to send us medical records and a prescriber statement to show the need for this medication. We did not receive the documentation requested.A physician reviewed your appeal and determined that the plan is not required to cover the Strensiq. The medical records show that Strensiq was prescribed to treat the enrollees hypophosphatasia. The Medicare approved compendia does support the use of this drug for hypophosphatasia. However, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria for prior authorization.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Bioidentical Hormone Replacement Therapy Heavy Cream prescribed daily. The Part D plan denied your request because the compounded components of the cream were not Part D drugs. We received an expedited reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Bioidentical Hormone Replacement Therapy Heavy Cream. Your physician stated that you have been on this for many years for hormone replacement.In review of the Medicare approved compendia, the components of Bioidentical Hormone Replacement Therapy Heavy Cream are not Food and Drug Administration approved. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the compounded cream at issue.