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

You requested Cosentyx 300 milligram pen injector prescribed for hidradenitis suppurativa. 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 Cosentyx pen injector for hidradenitis suppurativa. The Medicare approved compendia do not support the use of the biologic at issue for your conditions. As it cannot be determined that 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 a formulary exception request for Repatha Sureclick 140 milligram auto-injector prescribed for hyperlipidemia and atherosclerotic heart disease of native coronary artery without angina pectoris. 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 Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Jardiance 10 milligram tablets prescribed for the enrollees condition. 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.Jardiance is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed 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 Qinlock 50 milligram tablets prescribed as three tablets once daily to treat systemic mastocytosis. 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 the doctor prescribed Qinlock to treat systemic mastocytosis. The enrollee also has a history of myelodysplastic syndrome, and is currently treated with Rydapt and Tibsovo. The prescriber submitted medical literature for review. However, the Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.An oncologist reviewed your appeal and determined that the plan is not required to cover Qinlock.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nifedipine ER 90 milligram tablets to treat the enrollees 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.Nifedipine ER is a generic drug on Tier 3 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat your condition have been tried or deemed contraindicated. 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 prior authorization request for Nuedexta 20-10 milligram capsules prescribed for pseudobulbar affect due to Alzheimers 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 drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Kineret 100 milligrams/0.67 milliliters subcutaneous injection prescribed as directed for pseudogout. 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 the doctor prescribed Kineret to treat chronic crystal-proven chondrocalcinosis, also known as pseudogout. However, the Medicare approved compendia do not support the use of this drug for the enrollees 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 Imvexxy 10 microgram vaginal capsules prescribed for other specified non-inflammatory disorders of vagina and vaginal dryness. 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 originally prescribed Imvexxy for other specified non-inflammatory disorders of vagina and vaginal dryness. You have submitted a statement to indicate your diagnosis should be vaginal atrophy. However, the submitted documentation does not contain medical records to support a covered condition. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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 Syndros 5 milligram/milliliter solution prescribed for cyclical vomiting and gastroparesis. 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 Syndros for cyclical vomiting and gastroparesis. You submitted a statement indicating the prescribed diagnoses are incorrect and should be pancreatic disease, non-specified, sphincter of oddi dysfunction, nausea with vomiting, and eating disorder, unspecified. The Medicare approved compendia do not support the use of the drug at issue for your conditions. No medical records were submitted to support a covered 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 Xiidra 5% solution eye drop for dry eye 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. 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. We received the documentation and included it in our review.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 Xiidra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Yuvafem 10 microgram vaginal inserts prescribed for an unknown condition. The Part D plan denied the request because Yuvafem in not on the plans formulary and the documentation did not support a 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.During this review, a request was submitted to your doctor to provide a diagnosis, to address the medications that are on the formulary to treat your condition, and to provide supporting medical records. Your doctor did not respond to the request.Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, 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 the Yuvafem.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humira (CF) 40 milligrams per 0.4 milliliter pen prescribed to treat pyoderma gangrenosum. The Part D Plan denied the request stating that the provided diagnosis is 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.The medical records show the enrollee has a past medical history of ulcerative colitis. However, the prescriber indicates Humira is being prescribed for treatment of pyoderma gangrenosum. 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 Humira (CF) 40 milligrams per 0.4 milliliter pen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed to treat a contusion of the left knee. 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 5% patch to treat pain in an enrollee  with osteoarthritis of the left knee and a recent left knee contusion. 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 Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Felbamate 600 milligram tablets to treat major depressive disorder. 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.Felbamate 600 milligram tablets is a generic drug on Tier 4 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat your condition have been tried or deemed contraindicated. 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 Eliquis 5 milligram tablets prescribed as directed for paroxysmal atrial fibrillation. 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. Eliquis 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 a tiering exception request for Fanapt 6 milligram tablets prescribed for the enrollees condition. 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.Fanapt is a brand drug on Tier 4 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 Sancuso 3.1 milligrams per 24-hour patch to treat nausea related to cancer treatment that includes lanreotide and Sutent. 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 Sancuso 3.1 milligrams per 24-hour patch to treat nausea related to the administration of lanreotide. You are also on Sutent. 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 Sancuso 3.1 milligrams per 24-hour patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Advair Diskus 250 milligram/250 milliliter aerosol powder prescribed for the enrollees condition. 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.Advair Diskus 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 a request for coverage of Clotrimazole-Betamethasone 1-.05% cream, 135 grams per 30 days. The Part D plan denied the request for coverage because the amount requested exceeded the plans quantity limits. Additionally, the medication was being used for a non-medically accepted indication.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 Clotrimazole-Betamethasone has been prescribed for diabetic foot ulcers. 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. Since the drug is not eligible for coverage under Medicare Part D, the plans quantity limits are not relevant to this review. A physician reviewed the appeal and determined that the plan is not required to cover the Clotrimazole-Betamethasone cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Otezla 30 milligram tablets prescribed twice daily for plaque psoriasis. 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 drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nubeqa 300 milligram tablets prescribed as directed to treat hormone sensitive metastatic prostate 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 documentation shows the doctor prescribed Nubeqa to treat hormone sensitive metastatic prostate cancer. The enrollee has been treated with oral androgen deprivation therapy, but the prescriber is requesting the addition of Nubeqa due to the presence of high volume disease. The prescriber states the enrollee is not a candidate for other treatments for metastatic sensitive prostate cancer. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.An oncologist reviewed your appeal and determined that the plan is not required to cover Nubeqa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dapsone 5% gel to treat hidradenitis suppurativa. 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 Dapsone 5% gel to treat hidradenitis suppurativa. 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 Dapsone 5% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Butalbital-Acetaminophen 50-325 milligram tablets to treat chronic headaches. 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 Butalbital-Acetaminophen 50-325 milligram tablets to treat chronic headaches. 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 Butalbital-Acetaminophen 50-325 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tymlos 80 micrograms for subcutaneous injection prescribed daily for post-menopausal osteoporosis. 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 the doctor prescribed Tymlos to reduce the risk of fractures for an enrollee with post-menopausal osteoporosis. The documentation does not show that the enrollee has failed, or has a medical intolerance to, other osteoporosis therapy. 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 Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol sulfate 2.5 milligrams per 3 milliliters nebulizer solution prescribed for nebulization to treat the diagnosis of asthma. The Part D Plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Albuterol sulfate is being administered at home via a nebulizer. Based on the information provided, we have determined the requested drug is not eligible for Medicare Part D coverage, but may be covered under Part B benefits.A physician reviewed your appeal and determined that the Part D plan is not required to cover Albuterol sulfate 2.5 milligrams per 3 milliliters nebulizer solution.