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

You requested Tacrolimus 0.1 percent ointment prescribed for seborrheic dermatitis. 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 prescriber initially provided the diagnosis of seborrheic dermatitis. In the request for reconsideration, the prescriber changed the diagnosis to eczema and seborrheic dermatitis. Medical records were requested to support the change in diagnosis. We did not receive the requested records. Therefore, the drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Humulin N 100 units/milliliter Kwikpen.We received the case to perform an independent and de novo review. To make our decision, we read all documentation submitted. This includes any information submitted at the reconsideration level. Humulin N 100 units/milliliter Kwikpen 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 a formulary exception for Nurtec 75 milligram disintegrating tablets prescribed for acute migraine. 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 did not include medical records or a prescriber supporting statement. A request for additional documentation was sent to your doctor. A supporting statement was received; however, there were no medical records submitted to corroborate a prescribed diagnosis. 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 request for coverage of Motegrity 2 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 the enrollee has bloating, abdominal distension, and constipation associated with small intestinal bacterial overgrowth and that Motegrity has been prescribed for the constipation. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of constipation associated with small intestinal bacterial overgrowth. 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 the appeal and determined that the plan is not required to cover the Motegrity.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Onureg 300 milligram tablet prescribed for peripheral T-cell lymphoma. 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 Onureg 300 milligram tablet to treat the enrollees peripheral T-cell lymphoma. However, the Medicare approved compendia and Medicare approved journals do not support the use of this drug for this condition. An oncologist reviewed your appeal and determined that the plan is not required to cover Onureg 300 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Actemra ACTPen 162 milligrams per 0.9 milliliter subcutaneous injection pen. The Part D plan denied the request for coverage because the diagnosis of inflammatory polyarthropathy was not a medically accepted indication for use of the drug.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 includes two sets of progress notes from a physicians office visit for the same date of April 16, 2021. In the first set of progress notes, the physician notes that the enrollee is being treated for inflammatory oligo arthritis. There is no mention of rheumatoid arthritis. Additionally, the diagnosis provided by the physician on the initial request for medication form is inflammatory polyarthropathy without mention of rheumatoid arthritis. In the second set of progress notes the diagnosis has been changed to inflammatory oligoarthritis consistent with inflammatory polyarthritis seronegative rheumatoid arthritis. Due to the conflicting information regarding the condition being treated, it cannot be determined if the drug is being prescribed for a medically accepted indication as outlined in the Medicare approved compendia. Therefore, the drug is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the Actemra ACTPen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 620 microgram/2.48 milliliter solution pen injector 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. Forteo 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 True Metrix Glucose Test Strip prescribed for the diagnosis of diabetes, type 2. 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 True Metrix Glucose Test Strip because it is not considered a medical supply directly associated with the injection of insulin. Although, this supply is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. This decision does not address the medical necessity or appropriateness of the supply. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Retacrit 40,000 units/milliliter injection prescribed for stage IV chronic kidney disease. 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.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.The medical records show you prescribed Retacrit 40,000 units/milliliter injection to treat the enrollees chronic kidney disease. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation submitted now indicates that the enrollee is not currently on dialysis and the most recent hemoglobin level is 8.2 grams/deciliter. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Retacrit 40,000 units/milliliter injection.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Temozolomide 140 milligram oral capsules prescribed as directed for large cell lymphoma of the central nervous system. The Part D plan denied your request; the plan stated the drug was eligible for coverage under Medicare Part B. 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 Medicare approved compendia do not support the use of the injectable form of Temozolomide for this enrollees condition. Therefore, the oral form of the drug requested may be considered for coverage under Medicare Part D.The documentation shows the doctor prescribed Temozolomide to treat diffuse large B-cell lymphoma involving the pituitary stalk. The enrollee was previously treated with surgery and high-dose Methotrexate. The record shows the enrollee cannot tolerate further treatment with Methotrexate. The physician considered treatment with Rituxan, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone; the enrollee declined this treatment approach. Therefore, the physician recommended treatment with Temozolomide as a single agent in the adjuvant setting. However, the Medicare approved compendia do not support the use of this drug as prescribed for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Temozolomide 140 milligram oral capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolastin-C 1000 milligram injection prescribed for alpha-1 antitrypsin deficiency. 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.We asked for information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication is needed. We received the documentation and included it in our review. The medical records show you prescribed Prolastin-C 1000 milligram injection to treat the enrollees alpha-1 antitrypsin deficiency. The 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 Prolastin-C 1000 milligram injection. 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 Lidocaine 5% patch prescribed for chronic low back 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. We also researched Medicare systems and reviewed the enrollment data available.We asked for information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication is needed. We received some of the documentation and included it in our review.The medical records show you prescribed Lidocaine 5% patch to treat the enrollees chronic low back pain. The 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 Lidocaine 5% patch. 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 a request for coverage of Repatha SureClick 140 milligram per milliliter subcutaneous injection pen prescribed for homozygous familial hypercholesterolemia. 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 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 does not satisfy the plans coverage criteria for this medication. 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

At issue is Fulvestrant 250 milligram/5 milliliter intramuscular injection prescribed for metastatic breast cancer. 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 Fulvestrant 250 milligram/5 milliliter intramuscular injection to treat the enrollees metastatic breast cancer. This drug is eligible for coverage under Medicare Part B. This medication cannot be self-administered and will need to be provided incident to a healthcare professional service. We determined that the plan is not required to cover Fulvestrant 250 milligrams/5 milliliter intramuscular injection. You may wish to submit your claim to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulicity 0.75 milligram/0.5 milliliter pen injector prescribed for type 2 diabetes with hyperglycemia. 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. 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 formulary exception request for Livalo 1 milligram tablets prescribed for hyperlipidemia. 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 did not include a supporting statement. A request for additional information was sent to your physician. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Horizant ER 300 milligram tablet prescribed for neuropathic 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 medical records show your doctor prescribed Horizant ER for neuropathic pain. 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 Horizant ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec 75 milligram tablets disintegrating prescribed to treat migraines. 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 prescriber indicates that a couple of the plans alternative formulary drugs were tried and failed or could cause harm. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the records do not support why all 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 Nurtec 75 milligram tablets disintegrating.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Rasagiline Mesylate 1-milligram tablet to treat Parkinsons disease. 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.Rasagiline Mesylate is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Paricalcitol capsule 1 microgram prescribed for end state renal disease. The Part D plan denied your request because the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle when receiving dialysis.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 shows you received a kidney transplant and no longer require dialysis. We researched Medicare systems and reviewed the enrollment data available, which confirmed you are no longer receiving dialysis. Your doctor prescribed Paricalcitol for treatment of secondary hyperparathyroidism due to stage 3 chronic kidney disease. Laboratory studies submitted with the reconsideration request, performed on May 14, 2021, indicate this enrollees eGFR is >60. At this level of renal function (not Stage 3), the medication is not being requested for a medically accepted indication per the Medicare approved compendia. A physician reviewed your appeal and determined that the plan is not required to cover Paricalcitol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amlodipine Besylate 10 milligram tablet prescribed twice daily for unknown diagnosis. 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 your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.Medicare records indicate that Part D is the primary payor for this claim. The documentation shows your doctor prescribed Amlodipine Besylate. However, the records do not include a diagnosis to support a Medicare approved compendia use of this drug. It could not be determined whether the requested drug was being prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Amlodipine Besylate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Caplyta 42 milligram capsule to treat major depressive disorder, recurrent, with psychotic symptoms. 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

At issue is Octreotide Acetate 100 micrograms  prescribed twice daily for iron deficiency anemia. 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. The documentation shows the doctor prescribed Octreotide Acetate to treat the enrollees iron deficiency anemia. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Octreotide Acetate.