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

At issue is Lorazepam 0.5 milligram tablet to treat tinnitus. 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: Favorable

You requested Procrit Solution 2000 microgram/milliliter prescribed for anemia in chronic kidney disease. The Part D plan denied the request and indicated the drug is not eligible under Part D as it is used for end-stage renal disease and Medicare records show you are currently receiving dialysis. 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. Procrit Solution 2000 microgram/milliliter was prescribed to treat anemia in chronic kidney disease. Medicare records show that the enrollee was no longer receiving dialysis. The drug would be a Part D drug. The enrollee had a hemoglobin of 8.6 on May 29, 2021, and therefore met the prior authorization requirement.  A physician reviewed your appeal and determined that the plan is required to cover Procrit Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Toujeo Solostar 300 units/milliliter 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. Toujeo 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 Trihexyphenidyl prescribed for tremor-predominant atypical Parkinsonism.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. Your prescriber indicates that Trihexyphenidyl is prescribed for tremor-predominant atypical Parkinsonism. Medicare approved compendia supports this drug as an adjunct therapy. The compendia does not support this drug as prescribed.A physician reviewed your appeal and determined that the plan is not required to cover Trihexyphenidyl.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Androderm 4 milligram per 24 hour patches prescribed for hypogonadotropic hypogonadism. 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.Androderm 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 to treat the noted condition 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 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 Prevymis 480 milligram oral tablet. 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 Prevymis to treat your cytomegaloviral disease prophylaxis with history of kidney transplant. 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 Prevymis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Pushtronex System Solution Cartridge 420-milligrams/3.5-milliliters to treat primary hyperlipidemia. The Part D plan denied the request. The requested drug is not on the plans formulary. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Ampyra (Dalfampridine ER) 10 milligram extended release 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 Ampyra (Dalfampridine ER) has been prescribed for the treatment of spinocerebellar ataxia with downbeating nystagmus. 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 condition. 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 Ampyra (Dalfampridine ER).
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclophosphamide 50 milligram capsule prescribed for refractory myeloma. 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 eligible for coverage under Medicare Part B. Certain oral anticancer drugs are covered under the oral anticancer drug benefit, Social Security Act Section 1861(s)(2)(Q). We determined that the plan is not required to cover Cyclophosphamide 50 milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Dapsone 25 milligram tablet to treat the enrollees condition.   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.Dapsone is a generic drug on Tier 3 of the plans formulary. There are no drugs of the same type on the lower tiers of the plans formulary to treat the same condition. 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

At issue is Telmisartan 40 milligram tablets. 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 this medication. We did not receive the requested documentation.Your doctor prescribed Telmisartan 40 milligram tablets for your condition. The Part D plan denied your request for a formulary exception. However, no medical records have 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 Telmisartan 40 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Gel. At initial determination and redetermination the diagnosis of primary hypogonadism 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 erectile dysfunction was noted with the laboratory report dated January 26. 2021. No medical records were provided by the prescriber to support the diagnosis of primary hypogonadism. Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not FDA approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.A physician reviewed the appeal and determined that the requested drug is excluded from Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Basaglar 100 units/milliliter KwikPen 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. Basaglar 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 Dexilant capsule 60 milligram DR prescribed for gastroesophageal reflux disease. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.The record shows Dexilant was prescribed for gastroesophageal reflux disease. 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.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, we did not received medical records to support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover the Dexilant.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lansoprazole 30 milligram tablet to treat gastroesophageal reflux disease without esophagitis. The Part D plan denied the request. The requested drug is not on the plans formulary. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Eplerenone 25 milligram tablets prescribed for chronic systolic congestive heart failure. 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. 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 Eplerenone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sandostatin LAR depot kit 20 milligram prescribed for iron deficiency anemia and melena. 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 shows your doctor prescribed Sandostatin LAR for iron deficiency anemia and melena. 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 Sandostatin LAR.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine 10 milligram tablet prescribed for acute 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 information submitted at the reconsideration level. The medical records shows your doctor prescribed Cyclobenzaprine prescribed for acute low back 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 Cyclobenzaprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At initial determination and redetermination, Adcirca 20 milligram tablets was prescribed to treat systemic sclerosis scleroderma. The Part D plan denied your request as a non-medically accepted indication.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.At reconsideration, a provider office note of April 23, 2021, establishes the diagnosis of Secondary Raynauds phenomenon. According to DRUGDEX, Adcirca has a non-Federal Drug Administration medically-accepted indication (off label use) for the diagnosis of secondary Raynauds phenomenon.However, Adcirca is not on the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan (generic sildenafil) 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.A physician reviewed your appeal and determined that the plan is not required to cover Adcirca 20 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 3% gel prescribed for chronic pain, lumbar degenerative disc disease, and fibromyalgia. 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 Diclofenac Sodium 3% gel for chronic pain, lumbar degenerative disc disease, and fibromyalgia. 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 Diclofenac Sodium gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 3 milligram Enteric Coated Capsule to treat diarrhea secondary to radiation proctitis and prior chemotherapy treatment (Cisplatin). 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 Tresiba Flextouch 75 units daily (200 units/milliliter) prescribed for type II 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. 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 all other medications on the plan's formulary for your condition would not work for you. However, we did not receive the documentation.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 Tresiba.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Kineret 100 milligram/0.67 milliliter injection prescribed daily for periodic fever syndrome and familial Mediterranean fever. 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 Kineret to treat your periodic fever syndrome and familial Mediterranean fever. 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 Kineret.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Repatha Pushtronex 420 milligram/3.5 milliliters prescribed for arteriosclerotic cardiovascular disease. The Part D plan denied the request and indicated the drug was not medically indicated for the enrollees condition. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any records submitted at the reconsideration level. Repatha Pushtronex 420 milligram/3.5 milliliters was prescribed to treat arteriosclerotic cardiovascular disease. Medicare approved compendia support the drug is approved for the enrollees condition. However, the drug is not on the plans formulary. The medical records do not support the enrollee could not tolerate all of the alternate medications on the plans formulary. 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. There is no supporting evidence that all the plans formulary, alternative drugs, have been tried.A physician reviewed your appeal and determined that the plan is not required to cover Repatha Pushtronex.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets prescribed for diarrhea due to small bowel bacterial overgrowth. 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 and medical records were received. The documentation indicates your doctor prescribed Xifaxan for diarrhea due to small bowel bacterial overgrowth. The Medicare approved compendia do not support the use of the drug for your condition. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Retacrit Solution 10000 unit/milliliter prescribed for an enrollee status post a kidney transplant due to renal failure. The Part D plan denied the request and indicated the drug is not eligible under Part D as it is used for end-stage renal disease and Medicare records show you are currently receiving dialysis. 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. Retacrit Solution 10000 unit/milliliter was prescribed to treat an enrollee with chronic kidney disease. Medicare records show that the enrollee was no longer receiving dialysis. The drug would be a Part D drug. However, the drug is not on the plans formulary. There is no medical records to support the enrollee could not tolerate all of the alternate medications on the plans formulary. 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. A physician reviewed your appeal and determined that the plan is not required to cover Retacrit Solution.