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

You requested Venclexta Starter Pack 42 for 30 prescribed as directed to be given with Gazyva to treat your recurrent/relapsed chronic lymphocytic leukemia. 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 Venclexta Starter Pack to be given with Gazyva to treat your recurrent/relapsed chronic lymphocytic leukemia. The records indicate you have high risk chronic lymphocytic leukemia based on bone marrow biopsy mutation studies which was initially diagnosed in 2019, and was treated at that time with Gazyva and Chlorambucil. You did have neutropenia with six cycles. Treatment was completed in 2019, and imaging showed response. Recently, studies indicate clinical progression, patient does not have deletion 17p. Venclexta is not indicated with Gazyva as second line therapy. No Medicare approved journal articles support an exception. Therefore, a medically accepted indication is not present. A physician reviewed your appeal and determined that the plan is not required to cover Venclexta Starter Pack.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Cequa 0.09 percent ophthalmic drops prescribed as directed for keratoconjunctivitis sicca. 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 the physician prescribed Cequa to treat your keratoconjunctivitis sicca. The Medicare approved compendium supports the use of the requested drug for your condition. The records show that you cannot take other drugs on your plans formulary for your condition. Specifically, Artificial Tears, Genteal gel, Xiidra and Restasis, which states you were on for 15 years prior without relief. Cequa samples were given and improvement was seen in a little over two weeks. A physician reviewed your appeal and determined that an exception can be granted to cover the drug that is not on your plans formulary. Therefore, the plan is required to cover Cequa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Multaq 400 milligram tablet prescribed twice daily. 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. Multaq 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 Cresemba 186 milligram capsules prescribed to treat pulmonary histoplasmosis. 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 Cresemba 186 milligram capsules to treat pulmonary histoplasmosis. 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 Cresemba 186 milligram capsules.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Calcitriol 0.50 microgram capsule, a quantity of 30 capsules per 30 days prescribed for secondary hyperparathyroidism. The Part D plan denied the request stating the medication is end stage renal disease related and not covered under Medicare Part D.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(s). We also asked for medical records and other documentation to show why you need this medication. We received the documentation and included it in our review.We determined that the drug is not eligible for Part B coverage. The medical records support that the enrollee is no longer on dialysis. Therefore, the drug can be considered for payment under the Part D benefit.Your medical records support chronic kidney disease with secondary hyperparathyroidism. The following citation was referenced in DrugDex, a Medicare approved compendia, and supports the use of this drug for your condition: Calcitriol is indicated in predialysis patients for the management of secondary hyperparathyroidism and resultant metabolic bone disease in patients with moderate to severe chronic renal failure who are not yet receiving dialysis.A physician reviewed your appeal and determined that the plan is required to cover Calcitriol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clinisol 15%/Clinolipid 20%/Dextrose 70% prescribed for malnutrition. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. Your prescriber indicates Clinisol 15%/Clinolipid 20%/Dextrose 70% via intravenous infusion is prescribed to treat malnutrition. The prescriber indicates the enrollee has no gastrointestinal absorption problems and the drug should be covered under Part D. Part D drugs include parental nutrition administered by infusion for reasons other than a digestive track that does not work. However, when one or more drugs in a compound is not coverable, then the compound cannot be covered. Clinolipid 20% is not on your plans formulary. Therefore, the drugs for malnutrition cannot be approved. A physician reviewed your appeal and determined that the plan is not required to cover Clinisol 15%/Clinolipid 20%/Dextrose 70%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 25 milligram tablets. 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.Myrbetriq 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 Promethazine 25 milligram tablets prescribed every four hours as needed for chronic nausea with vomiting. 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 Promethazine to treat your chronic nausea with vomiting. 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 chronic nausea with vomiting.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil prescribed daily for dermatomyositis. 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 Mycophenolate Mofetil to treat dermatomyositis. However, the Medicare approved compendia do not support the use of this drug for your condition. As such, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz 5 milligram oral tablet prescribed twice daily for arthralgia in multiple sites. 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 Xeljanz to treat arthralgia in multiple sites. However, the Medicare approved compendia do not support the use of this drug for your condition. As such, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligram tablets prescribed for primary pulmonary hypertension. 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 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, as ordered, is not being used for a medically accepted indication. The requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligram/milliliter Sure Click prescribed as directed for mixed hyperlipidemia. 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 Repatha to treat your mixed hyperlipidemia. 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 Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mekinist 2 milligram tablets prescribed daily for metastatic melanoma with BRAF L597 mutation. 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 Mekinist for metastatic melanoma with BRAF L597 mutation (non-V600 mutation). The Medicare approved compendia and Medicare approved journal articles do not support the use of the drug at issue for your conditions. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Zolpidem Tartrate 10 milligram tablets prescribed for persistent insomnia. 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 a prior authorization request for Xifaxan 550 milligram tablets prescribed for irritable bowel syndrome with diarrhea. 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. A request for information was sent to the prescriber. The subscriber submitted 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

At issue is Corlanor 5-milligram tablet to treat supraventricular tachycardia and sinus tachycardia. 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 Rasuvo 15 milligram/0.3 milliliter auto-injector prescribed for rheumatoid arthritis. 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 and 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, 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 Rasuvo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 2 milligram sublinqual tablets prescribed for non-acute pain. The Part D plan denied your request stating that the drug was not used for a 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. Your prescriber indicates he is prescribing Buprenorphine Hydrochloride sublingual tablets for pain management due to non-acute chronic back and extremity pain. Medicare approved compendia does support the use of Buprenorphine Hydrochloride sublingual tablets for management of pain that is severe enough to require daily, around the clock, long-term opiate analgesia and for which alternative treatment options are inadequate. However, your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The prior authorization criteria were not met. A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride sublingual tablets. 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 Corlanor 5 milligram tablets prescribed for inappropriate sinus tachycardia. 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 they prescribed Corlanor 5 milligram tablets to treat your inappropriate sinus tachycardia. Medicare approved compendia do not support the use of this drug for this condition.  A physician reviewed your appeal and determined that the plan is not required to cover Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Dextroamphetamine-Amphetamine 20 milligram capsules prescribed for attention deficit hyperactivity disorder. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation 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 the formulary alternatives were tried and failed or were contraindicated.A physician reviewed your appeal and determined that the plan is not required to cover Dextroamphetamine-Amphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a prior authorization for Diclofenac Epolamine 1.3% patch prescribed for low back pain and other intervertebral disc degeneration. 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 Diclofenac Epolamine for low back pain and other intervertebral disc degeneration. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Estradiol 0.1% powder compounded in Versa Gel prescribed for vulvar atrophy. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your prescriber indicates Estradiol 0.1% compounded in Versa Gel prescribed to treat vulvar atrophy. Estradiol 0.1% powder is excluded from Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Estradiol 0.1%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Naprosyn 125 milligram/5-milliliter suspension prescribed as directed for moderately severe rheumatoid arthritis. 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 Naprosyn 125 milligram/5-milliliter suspension. Medicare does not allow Part D drug plans to cover drugs produced by a manufacturer that does not participate in the Medicare Gap Discount Program. The Centers for Medicare & Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. Records show that the manufacturer, ATNAHS Pharma US, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, the Part D plan is not required to cover Naprosyn 125 milligram/5-milliliter suspension. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitriol 0.5 microgram capsules prescribed for secondary hyperparathyroidism. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Medicare records indicate you are currently on dialysis. The drug at issue is bundled into the payment to the end-stage renal disease facility. This is eligible for coverage under Part B. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Calcitriol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dipyridamole 50 milligram tablets. 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. Dipyridamole is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you. 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.