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

At issue is Lidocaine 5% Patch to treat pain secondary to displaced intertrochanteric fracture of left femur. 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.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

You requested coverage for Armodafinil 150 milligram tablets. 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.The documentation indicates that Armodafinil has been prescribed for the treatment of multiple sclerosis related fatigue with excessive sleepiness. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed twice daily for low back pain and 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. The submitted documentation indicates your doctor prescribed Lidocaine 5% patch for low back pain and chronic pain syndrome. 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

At issue is Esomeprazole Magnesium 40 milligram tablet to treat gastroesophageal reflux disease. The Part D plan denied the request. The requested drug is not on the plans formulary. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The 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 Onetouch ultra test strips prescribed for the treatment of diabetes. The Part D plan denied your request. We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is not required to cover the Onetouch ultra test strips. According to Medicare rules, drugs that are not considered a medical supply directly associated with the injection of insulin are not covered under Part D. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. 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 Amitiza 8 microgram capsules prescribed twice daily for unspecified constipation. 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 Amitiza for constipation due to psychotropic medications. 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

At issue is Ceftriaxone 1-gram/50 milliliters to treat cellulitis. 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.Medications that are considered medical services by your plan are excluded from coverage by your prescription drug plan. Therefore, the requested drugs are excluded from coverage.A physician reviewed the appeal and determined that your plan is not required to reimburse you for the cost of the excluded drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vancomycin 1.25 grams/250 milliliters to treat cellulitis. 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.Medications that are considered medical services by your plan are excluded from coverage by your prescription drug plan. Therefore, the requested drugs are excluded from coverage.A physician reviewed the appeal and determined that your plan is not required to reimburse you for the cost of the excluded drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a tiering exception request for Ranolazine 500 milligram ER non-obstructive hypertrophic cardiomyopathy with anginal chest pain.   The Part D plan approved the formulary medication, but denied the tiering 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.Ranolazine 500 milligram ER is a generic drug on Tier 3 of the plans formulary.  At reconsideration, the prescriber has indicated that patient is on maximal doses of a combined verapamil and atenolol, with continued symptoms. Ranolazine is the only other drug, on the plans formulary to consider, per the medical literature, to treat the patients unique condition. The prescriber has stated that all lower tiered drugs to treat the condition have been tried and failed or provided reasons why they would likely not be as effective as the requested drug.  Therefore, this drug is eligible for a tiering exception.  Our physician reviewer's opinion is that tiering exception criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablets twice daily to treat the enrollees condition. 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.Eliquis 5 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tadalafil 20 milligram tablets prescribed for erectile dysfunction. 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 Tadalafil because it was prescribed to treat erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction 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 Gabapentin 100 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. The submitted documentation does not include medical records to indicate a prescribed diagnosis. A request for medical records was sent to your doctor to support a covered diagnosis; 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 tiering exception for Lantus Solostar 100 units/milliliter pen injector 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.Lantus Solostar is a brand biologic on Tier 3 of the plans formulary. There are no brand boiologics 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

At issue is Myrbetriq ER 50 milligram 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. The documentation shows Myrbetriq ER is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers for the enrollees condition. 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 a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tadalafil 20 mg tablet prescribed to treat your condition. 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. We did not receive the documentation requested.The records show your physician prescribed Tadalafil 20 mg tablet to treat your condition. There were no medical records submitted to determine if the drug was prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover Tadalafil 20 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol sulfate 2.5 milligram/3 milliliter solution prescribed for unknown diagnosis. The Part D plan denied your requestWe 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 record shows Albuterol sulfate is being administered through a nebulizer for use in the home setting. Medicare Part B covers supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Albuterol sulfate. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 90 milligram tablets to treat hypothyroidism. 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.Non-FDA approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram capsules prescribed for nausea and vomiting with gastroesophageal reflux disease and irritable bowel syndrome and prior history of brain tumor and seizure. 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 Dronabinol for nausea and vomiting with gastroesophageal reflux disease and irritable bowel syndrome and prior history of brain tumor and seizure. There is no evidence of chemotherapy induced nausea/vomiting. The Medicare approved compendia do not support the use of this drug for your condition. The records provided indicate that the drug was prescribed for a non-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: Favorable

At issue is Sildenafil Citrate 20 milligram tablets prescribed for systemic sclerosis Raynauds syndrome. 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 supports the drug was prescribed for the enrollees diagnosis of systemic sclerosis Raynauds syndrome. The Medicare approved compendia support Sildenafil Citrate in this condition.  Other prior authorization criteria per the plan, relate to the use of this drug for other conditions. The enrollee does satisfy medically accepted indications for the use of this drug.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Nystatin 100,000 units per gram topical powder. 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.The documentation indicates that Nystatin has been prescribed for lower extremity skin breakdown, rash, recurrent non-healing ulcers and cellulitis due to the presence of peripheral vascular disease. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Nystatin powder.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dexmethylphenidate HCl 40 milligram ER capsules prescribed for major depressive disorder. 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 Dexmethylphenidate HCl for major depressive 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 Cosentyx 300 milligrams prescribed as directed for psoriasis vulgaris. 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,The plan requires an intolerance or contraindication to conventional therapy before they will cover the requested drug. The prescriber has not sufficiently indicated why all alternatives required by the plan would likely cause harm or not be as effective for the enrollee as 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 Cosentyx.
Appeal type: Prescription Drug
Decision: Unfavorable

Vyvanse 10 milligram capsule was requested to treat the enrollees condition. The Part D plan denied your 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.A request was submitted to the prescriber to provide medical records to support a diagnosis of attention-deficit hyperactivity disorder.  A reply from the prescriber was not received.  Without a diagnosis supported by medical records, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 milligram tablets prescribed as directed. 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 reviewed your appeal carefully. We reviewed all documentation available.Jardiance 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 Testosterone Transdermal Gel 40.5 milligram/2.5 grams (1.62%) prescribed for testicular hypofunction. 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 also researched Medicare regulations and Medicare approved compendia. The Medicare approved compendia does not support the use of the drug for your conditionA physician reviewed your appeal and determined that the plan is not required to cover Testosterone Gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Xifaxan 550 milligram tablets prescribed twice daily. 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. This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that a tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Auryxia 210 milligram tablets prescribed to treat anemia in chronic kidney disease in an enrollee not on dialysis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. Vitamins and minerals are excluded from coverage under Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Auryxia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kesimpta 20 milligram per 0.4 milliliter pen to treat multiple sclerosis. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read all documentation submitted. This includes the 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. Our physician reviewer's opinion is that formulary exception criteria are not met.