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

At issue is Linzess 290 microgram capsule prescribed for chronic idiopathic constipation. The case was auto-forwarded by the plan.  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 requested additional information from the prescriber to support the reported allergic reaction to Trulance therapy but did not get a response. 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 documentation does not clearly support why all other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Linzess.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets prescribed for bloating. 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 Xifaxan for bloating. The prescriber submitted a statement to indicate the diagnosis should be irritable bowel syndrome with diarrhea; however, the progress notes submitted do not support the change in diagnosis and support the enrollee was prescribed Xifaxan for bloating and has constipation. The Medicare approved compendia do not support the use of the drug 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 Gammagard Solution 10 gram/100 milliliter prescribed for small fiber neuropathy. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber indicates that Gammagard Solution is prescribed for small fiber neuropathy. 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 Gammagard Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablet prescribed for palpitations/supraventricular tachycardia, postural orthostatic tachycardia syndrome, and tachycardia, unspecified. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber indicates that Corlanor is prescribed for palpitations/supraventricular tachycardia, postural orthostatic tachycardia syndrome, and tachycardia, unspecified. 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 Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vumerity 231 milligram delayed release capsule prescribed two capsules twice daily for multiple sclerosis. The Part D plan did not make a decision.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 that other drugs on the plans formulary would not work. A physician reviewed the appeal and determined that the plan is not required to cover Vumerity 231 milligram delayed release capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cresemba 186 milligram capsule prescribed for prevention of invasive aspergillosis post heart transplant. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber indicates that Cresemba 186 milligram capsule is prescribed for prevention of invasive aspergillosis post heart transplant. 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 Cresemba.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tagrisso 80 milligram tablet prescribed for metastatic non-small cell lung cancer. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records show that Tagrisso was prescribed for an enrollee with non-small cell lung cancer that was diagnosed in 2007 with early stage disease status post resection. In 2021 the enrollee presented with a large lung mass and adenopathy along with possible bony disease. Pathology showed non-small cell carcinoma, consistent with lung primary with an EGFR G719A mutation and EGFR S7681 mutation and EGFR amplification. The enrollee started Keytruda but developed pleural effusions and could not tolerate it. Due to EGFR mutations, it is being requested that Tagrisso be approved as a second line therapy. Per Micromedex, Tagrisso is listed as an orphan drug for treatment of EGFR mutation positive non-small cell lung cancer. The provider submits an article from a Medicare approved journal, Journal of Clinical Oncology, called Osimertinib for Patients with Non-Small Cell Lung Cancer Harboring Uncommon EGFR Mutation: A Mutlicenter Open Phase 2 Trial. In the study, it states that 10% of EGFR mutations are uncommon and determined if Tagrisso had efficacy in these rare EGFR mutations. The study is directly applicable to the enrollee as the enrollee has never been on EGFR therapy before, one of the criteria of the study, and the type of mutation patient has was included in the study. Tagrisso showed that it had an ORR of 50% in rare EGFR mutation positive patients and that it increased PFS, both of which were meaningful results. Because it is an orphan drug designation for Tagrisso, to be used in EGFR mutated lung cancer and is supported by a Medicare approved journal article directly applicable to patient, it can be approved.A physician reviewed your appeal and determined that the plan is required to cover Tagrisso.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sucralfate 100 milligram/milliliter suspension prescribed for peptic ulcer disease. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. 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 all the other drugs on the plans formulary would not work. The prescriber indicates that the enrollee cannot take Sucralfate tablets and only the oral suspension works but there was no reason as to why the enrollee could not take the formulary alternative Famotidine oral suspension.A physician reviewed your appeal and determined that the plan is not required to cover Sucralfate suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carbinoxamine Maleate 4 milligram tablet prescribed for allergic rhinitis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. 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 prescriber does not indicate why all other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Carbinoxamine Maleate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 microgram inhaler prescribed for chronic obstructive pulmonary disease. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. 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 prescriber does not indicate why all other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulance 3 milligram tablets prescribed for irritable bowel syndrome with constipation. 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 your appeal and determined that the plan is not required to cover Trulance.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 3% gel prescribed for back and wrist pain. 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 Diclofenac Sodium 3% gel for back and wrist pain. The Medicare approved compendia do not support the use of the drug for the enrollees condition. As it 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 Benzonatate 200 milligram capsules to treat a cough.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 determined that the plan is not required to cover Benzonatate 200 milligram capsules because drugs used for the symptomatic relief of cough and cold are excluded from coverage under Medicare Part D. If the enrollee has purchased drugs/products that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug/product. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Zolpidem Tartrate 10 milligram tablets prescribed as directed for insomnia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Zolpidem Tartrate to treat your insomnia. Your 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 reimburse Zolpidem Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Voriconazole 200 milligram solution prescribed for sinus cultures positive for purpureocillium lilacinus. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber indicates that the enrollee had sinus cultures positive for purpureocillium lilacinus which needs to be treated with Voriconazole nasal rinses. The medical records support Voriconazole solution is being requested for nasal rinses to treat sinus cultures that were positive with purpureocillium lilacinus. 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 Voriconazole.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gammagard 20 gram/200-milliliter solution prescribed as directed for sarcoid myositis. 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 Gammagard to treat your sarcoid myositis. 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 Gammagard.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Econazole Nitrate 1% cream (gram) prescribed to treat a rash. The Part D plan denied the formulary exception 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 the doctor prescribed Econazole Nitrate 1% cream (gram) to treat an enrollee with a rash to the back region and skin folds. Upon redetermination, the Part D plan denied the appeal request stating the formulary exception criteria was not met. However, the medical record provided fails to specify the type of rash the enrollee presented upon examination. The Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Econazole Nitrate 1% cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cosentyx 300 milligram dose 2 pens 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 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 included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.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 Toujeo Max Solostar 300 unit/milliliter pen prescribed for type 2 diabetes mellitus. 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 your appeal and determined that the plan is not required to cover Toujeo Max Solostar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 milligram tablets prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.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.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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Finasteride 1 milligram tablet prescribed as directed for benign prostatic hyperplasia. 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, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Finasteride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets prescribed for small intestine bacterial overgrowth. 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 Xifaxan for small intestine bacterial overgrowth. The Medicare approved compendia do not support the use of the drug for the enrollees condition. As it 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

You requested prior authorization for Modafinil 100 milligram tablets prescribed as directed for other fatigue and hypersomnia, unspecified. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Modafinil to treat your other fatigue and hypersomnia, unspecified. 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 Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Xifaxan 550 milligram tablets prescribed for irritable bowel syndrome with diarrhea. The Part D plan denied coverage.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 on hand does not indicate that the enrollee satisfies the plan's prior authorization 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 Mycophenolate Mofetil 500 milligram prescribed for interstitial lung disease. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber indicates that Mycophenolate Mofetil 500 milligram tablets are requested to treat interstitial lung disease. 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Teriparatide 620 microgram/2.48 milliliter injection prescribed for fusion of lumbar spine, metabolic bone disease, vitamin D deficiency, and low bone mass. 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 Teriparatide for fusion of lumbar spine, metabolic bone disease, vitamin D deficiency, and low bone mass. The Medicare approved compendia do not support the use of the drug for the enrollees condition. As it 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.