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

You requested coverage for Anoro Ellipta 62.5-25 microgram inhalation powder 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.Anoro Ellipta is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans 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 Xerava 50 milligram intravenous solution prescribed twice daily for Mycobacterium abscesses of prosthetic joint infection and osteomyelitis. 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. Your medical records show your doctor prescribed Xerava to treat your Mycobacterium abscesses of prosthetic joint infection and osteomyelitis. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and determined that the plan is not required to cover the Xerava.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Clobazam 20 milligram tablets. The Part D plan denied the request for coverage.  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 submitted medical records indicate that Clobazam has been prescribed to treat symptomatic generalized epilepsy with seizures. However, the Medicare approved compendia do not contain any citations to support the use of Clobazam for the treatment of symptomatic generalized epilepsy with seizures.At reconsideration, the prescriber has noted that the enrollee has Lennox-Gastaut syndrome, which is a complex, rare, and severe childhood-onset epilepsy. However, none of the submitted medical records indicate that the enrollee has Lennox-Gastaut syndrome. Therefore, there is insufficient documentation to determine if the Clobazam is being prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the plan is not required to cover Clobazam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Northera 100-milligram tablet to treat neurogenic orthostatic hypotension related to diabetic neuropathy. 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 Lidocaine/Prilocaine 2.5-2.5% topical cream 510 grams per 30 days prescribed for bilateral plantar fasciitis, plantar fascial fibromatosis, and right ankle joint 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 information submitted at the reconsideration level. The documentation shows your doctor prescribed Lidocaine/Prilocaine to treat your bilateral plantar fasciitis, plantar fascial fibromatosis, and right ankle joint pain. However, the Medicare approved compendia do not support the use of this drug for your condition(s). A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine/Prilocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gamunex-C 20 gram per 200 milliliter vial for intravenous infusion to treat D80.1 - Nonfamilial hypogammaglobulinemia.  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.The prescriber was asked to provide relevant medical records to support the submitted diagnosis.  The submitted medical records do not support the diagnosis of D80.1 - Nonfamilial hypogammaglobulinemia.   Therefore, It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Nexletol 180 milligram tablets. The Part D plan denied the request for coverage.  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 Nexletol has been prescribed for hyperlipidemia and fatty liver.  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 Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Diclofenac Epolamine 1.3% patches. The Part D plan denied the request for coverage.  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 submitted medical records indicate that Diclofenac Epolamine patches have been prescribed for the treatment of chronic pain, strain, and spasm of the lower back, without history of recent injury. However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, 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 Diclofenac Epolamine 1.3% patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Humira Starter Pack, 40 milligram per 0.4 milliliter subcutaneous injection pens. The Part D plan denied the request for coverage.  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 Humira has been prescribed for sarcoidosis and sarcoid myocarditis. 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 Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Heplisav-B solution pre-filled syringe prescribed for immunization/prophylaxis hepatitis B. 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 determined that the plan is not required to cover Heplisav-B because the manufacturer does not participate in the Medicare Coverage Gap Discount Program. Drugs from non-participating manufacturers are excluded from coverage. 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 Vascepa 1 gram capsules prescribed daily for atherosclerotic heart disease of native coronary artery without angina pectoris. The Part D plan denied your request because the documentation did not support an off-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 also researched Medicare systems and reviewed the enrollment data available. 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 the Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligrams per milliliter solution auto-injector, two pens for 28 days prescribed for bilateral carotid stenosis and hyperlipidemia. 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. Repatha Sureclick is a biological product drug on Tier 3 of the plans formulary. There are no biological product 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 request for coverage of Cyclobenzaprine Hydrochloride 10 milligram tablets. The Part D plan denied the request for coverage.  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 Cyclobenzaprine Hydrochloride has been prescribed for muscle spasms due to a chronic condition, intervertebral disc prolapse. However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, as prescribed, for the treatment of the muscle spasms related to chronic conditions. 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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulicity 0.75 milligram/0.5 milliliter solution pen-injector prescribed twice daily to treat the enrollee's condition.  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. Trulicity is a biological product drug on Tier 3 of the plans formulary. There are no biological product drugs of the same type on the lower cost sharing tiers to treat 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 your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligrams/milliliter injection pen prescribed as directed for atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. 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. We also researched Medicare systems and reviewed the enrollment data available. Repatha is a biological product drug on Tier 3 of the plans formulary. There are no biological product 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 Hetlioz 20-milligram tablet. At initial determination and redetermination the diagnosis of blindness right eye category 5, blindness left eye category 5 was given. 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.At reconsideration a diagnosis of posterior ischemic optic neuropathy was given. Additionally, a diagnosis of chronic insomnia due to circadian rhythm imbalance was indicated. No medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 coverage for Marinol 5 milligram capsules prescribed daily for nausea, vomiting, and weight loss associated with gastroparesis. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Marinol for nausea, vomiting, and weight loss associated with gastroparesis. In review of the Medicare approved compendia, nausea, vomiting, and weight loss associated with gastroparesis is not a medically accepted indication for Marinol. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the drug at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Octreotide 100 microgram/milliliter prescribed for cirrhosis induced hepatorenal 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 records show you prescribed Octreotide 100 microgram/milliliter to treat the enrollees cirrhosis induced hepatorenal syndrome. However, the Medicare approved compendia do not support the use of this drug for this condition as prescribed. A physician reviewed your appeal and determined that the plan is not required to cover Octreotide 100 microgram/milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Budesonide EC 3 milligram capsules prescribed for chronic diarrhea, nausea and vomiting due to lymphocytic gastritis and autoimmune enteritis. 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 Budesonide EC to treat your chronic diarrhea, nausea and vomiting due to lymphocytic gastritis and autoimmune enteritis. However, the Medicare approved compendia do not support the use of this drug for your condition. Additionally, the notes indicate that this drug was trialed with no relief of symptoms. 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 Budesonide EC. 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 Basaglar 100 units/milliliter Kwikpen prescribed as directed for uncontrolled type 2 diabetes mellitus with hyperglycemia. The Part D plan denied your request because the documentation did not support an off-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 also researched Medicare systems and reviewed the enrollment data available. 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 the Basaglar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alphagan P solution 0.1% prescribed for the diagnosis of primary open-angle glaucoma. 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.Alphagan P 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 Xifaxan 550 milligram tablets prescribed for irritable bowel syndrome with diarrhea.   The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read 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 medical 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

You requested Butalbital-Aspirin-Caffeine-Codeine 50-325-40-30 milligram capsules prescribed for tension headaches. 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 record shows that the enrollee is currently locked-in with one prescriber, Dr. Yuen Cheng, for all opioid medications. The requested medication contains an opiate, Codeine, and has not been prescribed by Dr. Cheng. We reviewed your appeal and determined that the plan is not required to cover the Butalbital-Aspirin-Caffeine-Codeine.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked for reimbursement for Boostrix Vaccine Syringe 1 time dose.  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 information provided does not include a receipt showing the amount was paid. There are only amounts showing as due on the documents.A physician reviewed your appeal and determined that the plan is not required to reimburse the amount of the Boostrix Vaccine Syringe.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colistimethate Sodium Powder 150 milligrams prescribed to treat cystic fibrosis. 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. We also researched Medicare regulations and reviewed the enrollment data available. Bulk powders are not approved by the food and drug administration and are therefore not covered under Part D.A physician reviewed your appeal and determined that the plan is not required to cover Colistimethate Sodium Powder.