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

You requested Ketamine 50 milligram/5 milliliter injection prescribed for chronic 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 record shows Ketamine is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover Ketamine. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vyvanse 50 milligram capsules to treat anxiety and bipolar disorders. The Part D plan denied your request for a 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 asked the 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 requested documentation.The documentation shows your doctor prescribed Vyvanse 50 milligram capsules to treat anxiety and bipolar disorders. However, the Medicare approved compendia do not support the use of this drug for your conditions. Since the requested drug will not be covered, your request for a formulary exception cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover Vyvanse 50 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Emend 80 milligram capsules prescribed for nausea due to gastroparesis. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates your doctor prescribed Emend for nausea due to gastroparesis. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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 Northera 300 milligram capsules prescribed for syncope and collapse. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows your doctor prescribed Northera to treat your syncope and collapse. 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 Northera.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine/Dextroamphetamine 20 milligram tablets prescribed for major depressive disorder, recurrent, moderate. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows your doctor prescribed Amphetamine/Dextroamphetamine to treat your major depressive disorder, recurrent, moderate. 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 Amphetamine/Dextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lupron Depot 3.75-milligram Kit intramuscular to treat pedophilia. 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 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 Latuda 40 milligram tablets 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. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates your doctor prescribed Latuda for major depressive disorder. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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 Otezla 30 milligram tablet prescribed for lichen planus. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Otezla to treat your lichen planus. 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 Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5 milligram tablet, a quantity of 30 tablets for 30 days prescribed for benign prostatic hyperplasia. We received an auto-forwarded reconsideration request from the coverage level.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, medical records have not been submitted to 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 Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spravato 56-milligram Nasal Spray to treat treatment resistant 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided records. 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 Oxycontin Extended Release 60 milligram tablet, a quantity of 60 tablets for 30 days prescribed for rheumatoid arthritis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, medical records have not been submitted to support why other drugs on the plans formulary would not work for you. In addition, it is noted that your prescriber requested that you take the generic Oxycodone Extended Release tablet. As such, an off formulary exception cannot be granted at this time for the brand Oxycontin Extended Release tablet.A physician reviewed your appeal and determined that the plan is not required to cover Oxycontin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24-26 milligram tablet, a quantity of 60 tablets per 30 days for chronic heart failure. 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. Entresto 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 Erythromycin 250 milligram filmtab prescribed for idiopathic gastroparesis. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates your doctor prescribed Erythromycin for idiopathic gastroparesis. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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 Repatha 140-milligrams/milliliter to treat familial hypercholesterolemia. 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

At issue is Rytary Extended Release 36.25 milligram-145 milligram capsule, a quantity of 270 capsules per 30 days for Parkinsons 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. Rytary 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. 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: Favorable

You requested Budesonide 0.5 milligram/2 milliliter respules prescribed for eosinophilic esophagitis. 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 medical records show your doctor prescribed Budesonide for eosinophilic esophagitis. The Medicare approved compendium indicates the drug at issue is labelled an orphan drug to treat your condition. The Medicare approved compendia support the use of the drug for your condition. A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500-milligram tablet. At initial determination and redetermination the diagnosis of sarcoidosis of lung was given. 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.We asked the prescriber to send us a prior authorization, prescriber statement, a medically accepted indication, and medical records. We received the requested documentation from your prescriber.At reconsideration a diagnosis of systemic sclerosis related to interstitial fibrosis was given. The use of the requested drug to treat the provided diagnoses are off-label uses. 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 Gattex Injection Kit prescribed daily for 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. The documentation shows your doctor prescribed Gattex to treat your short bowel syndrome. However, the Medicare approved compendia do not support the use of this drug for your condition due to not being dependent on parenteral support.A physician reviewed your appeal and determined that the plan is not required to cover Gattex.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcipotriene-Clobetasol Propionate 0.05% solution prescribed for psoriasis. 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 record shows your physician prescribed Calcipotriene-Clobetasol Propionate for psoriasis. The drug at issue is not Food and Drug Administration approved. 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.We determined that the plan is not required to cover Calcipotriene-Clobetasol Propionate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Oxervate 0.002% eye drops prescribed for neurotrophic keratitis. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trintellix 20 milligram tablets 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.Trintellix 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

At issue is a prior authorization request for Zolpidem Tartrate 10 milligram tablets prescribed for insomnia. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 150 milligram tablets prescribed for hypersomnolence related to multiple sclerosis. 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 Armodafinil 150 milligram tablets prescribed for hypersomnolence related to multiple sclerosis. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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 Corlanor 5-milligram tablet to treat inappropriate sinus tachycardia. 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 Diclofenac Epolamine patch 1.3% prescribed twice daily for acute pain due to minor strain, sprain. 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. Your doctor prescribed Diclofenac Epolamine to treat your acute pain in lower back due to minor strain, sprain. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Diclofenac Epolamine 1.3% topical system is indicated for topical treatment of acute pain due to minor strains, sprains, and contusions in adults and pediatric patients 6 years or older.However, 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, medical records have not been submitted to 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 Diclofenac Epolamine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hyalgan 20 milligram/milliliter injection for bilateral knee 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.We determined that the plan is not required to cover Hyalgan because it does not meet the definition of a Part D drug. The Hyalgan at issue is not approved by the Food and Drug Administration as a drug, it is indicated as a medical device and is excluded from coverage. Your plan does not offer supplemental (additional) coverage for Hyalgan. If you purchased items that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the Hyalgan. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolic 180-milligram tablet. 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 performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The record shows you were enrolled in Medicare Part A at the time of your kidney transplant on November 8, 2012. This drug is eligible for coverage under Medicare Part B. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.