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

At issue is Entresto 49/51 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 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 Acyclovir 5% ointment prescribed daily for herpes simplex. 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 Acyclovir to treat your herpes simplex. However, the Medicare approved compendia do not support the use of this drug for your condition. You are not immunocompromised.A physician reviewed your appeal and determined that the plan is not required to cover Acyclovir.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Nexium 40 milligram DR capsules prescribed for gastroesophageal reflux disease. 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 physician submitted a supporting statement to indicate formulary alternatives were tried and failed. However, there were no medical records submitted to support the information on the statement. The documentation does not support you have tried and failed all formulary alternatives. A physician reviewed your appeal and determined that the plan is not required to cover Nexium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Welchol 625 milligram tablets prescribed to take 4 tablets per day to treat high cholesterol level. 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 Welchol 625 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Aranesp (albumin free) 100 microgram/0.5 milliliter solution prefilled syringe prescribed for anemia in chronic kidney disease related to a kidney transplant. 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 record shows the enrollee had a kidney transplant on April 28, 2021. According to Medicare enrollment records, the enrollee was entitled to Medicare Part A coverage at the time of the transplant. Therefore, the transplant is considered a Medicare covered transplant and Aranesp is eligible for coverage under Medicare Part B. Medicare Part B covers prescription drugs used in immunosuppressive therapy furnished to an enrollee who has received an organ transplant. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. We determined that the Medicare Part D plan is not required to cover Aranesp. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Favorable

You requested Droxidopa 100 milligram capsules prescribed for symptomatic orthostatic hypertension. 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 plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation supports the diagnosis of symptomatic neurogenic orthostatic hypotension and a cause of pure autonomic failure as evidenced by a drop in systolic blood pressure of more than 20 millimeters of mercury when transitioning to a standing position. The documentation also supports that the drug was prescribed in consultation with a cardiologist. The medical records also show that the enrollee had insufficient results with Fludrocortisone and initially the symptoms were better on Midodrine but eventually required increasing the dosage. Even with increased dosage, she continued to note dizziness with standing. The plans prior authorization requirements were met. A physician reviewed your appeal and determined that the plan is required to cover Droxidopa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Humira CF 80 milligram/0.8 milliliter pen prescribed for Crohns disease. 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 biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine-Dextroamphetamine 20 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 Amphetamine-Dextroamphetamine for major depressive disorder. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As the drug was not 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 Diclofenac Sodium 1% gel prescribed for osteoarthritis. 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. Your medical records show your doctor prescribed Diclofenac Sodium to treat your osteoarthritis. 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 cover Diclofenac Sodium. The medical records do not support the drug is medically necessary because your physician has a concern for intolerance or a contraindication to two oral nonsteroidal anti-inflammatory drugs. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% patch. The Part D plan denied your request stating that the provided diagnoses of chronic pain syndrome, cervical spondylosis, lumbar stenosis, fibromyalgia, and low back pain were non-medically accepted indications.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 additional medical records or other documentation to support and verify the diagnosis and to show why you need this medication. We did not receive the additional documentation requested.On reconsideration, the appeal letter states, The patient now has a new pain problem: acute sprain and contusion of the left ankle. However, the clinic notes fail to support this diagnosis. Additional medical records have not been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Epolamine 1.3% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Topiramate 100 milligram tablets prescribed to treat bipolar disorder. 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 Topiramate 100 milligram tablets to treat bipolar disorder. 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 Topiramate 100 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin Hydrochloride 500 milligram extended release 24-hour tablet prescribed four times daily for type 2 diabetes mellitus. 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. Your medical records show your doctor prescribed Metformin Hydrochloride to treat your type 2 diabetes mellitus. 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 cover Metformin Hydrochloride. The physician has stated that you have not experienced an intolerance to Glucophage. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Ocrevus 300 milligram/10 milliliter injection prescribed for 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 Ocrevus for multiple sclerosis. There were no medical records or supporting statement on file. A request for information was sent to your doctor. A supporting statement was received; however, no medical records were submitted to corroborate the information on the statement. As it cannot be determined the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fosrenol 1000-milligram tablets prescribed three time daily for hyperphosphatemia. 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. Your prescriber indicates you tried and failed Calcium Acetate and Sevelamer and Auryxia is contraindicated. In this case, the medical records do not support why all other drugs on the plans formulary would not work for youA physician reviewed your appeal and determined that the plan is not required to cover Fosrenol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ingrezza 80 milligram capsules prescribed daily for tardive dyskinesia. 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 Ingrezza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxymorphone 10-milligram tablet to treat chronic low back and hip 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 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 Otezla 30 milligram oral tablet prescribed twice daily for psoriasis, chronic in nature. 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 Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron 8 milligram disintegrating tablets prescribed for nausea due to umbilical hernia and poor eating habits. 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 Ondansetron for nausea due to umbilical hernia and poor eating habits. The documentation did not include medical records to support a prescribed diagnosis. A request for records was sent to the prescriber; however, no 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 request for Leflunomide 10 milligram tablets prescribed for rheumatoid arthritis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read 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. Leflunomide is a generic drug on Tier 3 of the plans formulary. The prescriber has not sufficiently addressed all of the generic drugs of the same type on the lower tiers of the plans formulary to treat the noted condition. The prescriber has not explained why each lower tier alternative has been tried and failed or is contraindicated. A physician reviewed the appeal and determined that the plan is not required to cover the Leflunomide at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol 90 microgram inhaler. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.There was no diagnosis given at initial determination. No medical records have been submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia and why other medications on the plan's formulary world not work for you. As such, 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 Albuterol. The formulary exception was not addressed because the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doxepin Hydrochloride 25-milligram capsule. At initial determination and redetermination the diagnosis of insomnia, unspecified was given. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.At reconsideration diagnosis of insomnia due to chronic pain and depression was given. No medical records were provided by the prescriber to support this diagnosis. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed, with support of medical records, the issues regarding this high-risk medication, and why alternative safer medications, in the plan's formulary, could not be used. 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 Fentanyl 400 microgram oral lozenge prescribed up to 4 times a day for back and neck pain. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your records show your doctor prescribed Fentanyl to treat your back and neck pain. 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 cover Fentanyl. There is no evidence that you have pain related to cancer. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitriol 0.25 microgram capsules prescribed for the enrollees condition. The Part D plan denied the 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 used for dialysis-related services. Dialysis-related medications are included in the bundled payment that Medicare pays to dialysis centers under Medicare Part B. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Calcitriol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kineret 100-milligrams/0.67-milliliter Solution Prefilled Syringe to treat chondrocalcinosis, unspecified site. 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.