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

You requested Diclofenac Sodium 1 percent gel prescribed for post laminectomy syndrome, not elsewhere classified. 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. The documentation shows your doctor prescribed Diclofenac Sodium to treat your post laminectomy syndrome, not elsewhere classified. 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 1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is  Symbicort 160 mcg-4.5 mcg/actuation hfa aerosol inhaler prescribed for 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. Symbicort 160 mcg-4.5 mcg/actuation hfa aerosol inhaler is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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 Mavyet 100 milligram-40 milligram tablets prescribed for hepatitis C. 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 Mavyet to treat your hepatitis. The medical records show that you have hepatitis C, chronic Genotype 1A. There is no indication that you were treatment naive or previously treated with interferon, ribavirin, sofosbuvir or NS3/4 or NS5A. Therefore, Medicare approved compendia do not support the use of the drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Mavyet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Enbrel 50 milligram/milliliter syringe to treat necrobiosis lipoidica. The Part D plan denied your 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 prescriber statement and medical records show Enbrel was prescribed to treat necrobiosis lipoidica. 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 Enbrel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablet prescribed two tablets daily for small intestinal bacterial overgrowth. 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 records submitted at the reconsideration level.The medical records show the doctor prescribed Xifaxan to treat the enrollees small intestinal bacterial overgrowth. 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 the appeal and determined that the plan is not required to cover Xifaxan. 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 Mesalamine 400 milligram delayed release capsules  prescribed two capsules three times a day for ulcerative colitis. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. 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 Mesalamine 400 milligram delayed release capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 200 milligram tablet prescribed for trigeminal neuralgia and other fatigue. The Part D plan denied your 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 prescriber statement and medical records show Modafinil was prescribed for trigeminal neuralgia and other fatigue. However, the Medicare approved compendia do not support the use of this drug for your conditions. A physician reviewed your appeal and determined that the plan is not required to cover Modafinil.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Clobazam 20 milligram tablets prescribed for epilepsy. 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 prescriber indicates you are taking this medication since May 16, 2017, and your diagnosis is intractable Lennox-Gastaut syndrome with status epilepticus. The office record submitted from May 12, 2021, supports that you met criteria for Lennox-Gastaut syndrome. The Medicare approved compendia support the use of this drug for your condition. This drug has prior authorization rules that apply to new starts only.A physician reviewed your appeal and determined that the plan is required to cover Clobazam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 8 milligram sublingual tablet prescribed four times daily for chronic pain syndrome. 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 records submitted at the reconsideration level.The medical records show the doctor prescribed Buprenorphine Hydrochloride to treat the enrollees chronic pain syndrome. 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 the appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride 8 milligram 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 Ocetreotide 100 microgram injection prescribed for arteriovenous malformation. 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 Ocetreotide to treat your arteriovenous malformation. 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 Ocetreotide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligram tablets prescribed for insomnia. 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.The documentation submitted supports you requested Zolpidem Tartrate. 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 Zolpidem Tartrate. There are no medical records to support you suffer from insomnia. 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 coverage for Amphetamine-Dextroamphetamine 10 milligram tablets, 135 tablets per 30 days, prescribed for attention deficit disorder, inattentive type. The Part D plan approved the request for the Amphetamine-Dextroamphetamine 10 milligram tablets, 60 tablets for 30 days. However, the plan denied the request for 135 tablets per 30 days, as it exceeded the quantity allowed by the plan.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 Part D plan limits the quantity of Amphetamine-Dextroamphetamine 10 milligram tablets to 60 tablets per 30 days. The submitted documentation does not support an exception to the quantity limit criteria. A physician reviewed the appeal and determined that the plan is not required to cover more than 60 tablets per 30 days of Amphetamine-Dextroamphetamine 10 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Visbiome Probiotic 900B powder. 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 reviewed your appeal carefully. We reviewed all documentation available. Drugs prescribed that are available over the counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.We determined that the plan is not required to cover Visbiome Probiotic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Envarsus XR 0.75 milligram tablets prescribed following a heart transplant. 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. We also researched Medicare systems and reviewed the enrollment data available. Your records show your doctor prescribed Envarsus to prevent rejection following a heart transplant. The Medicare approved compendia support the use of this drug for your condition. Based on the information provided, the drug is eligible for Part B coverage. Therefore, the drug is not eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is not required to cover Envarsus XR.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lynparza 150 milligram tablets prescribed for metastatic serous endometrial cancer. 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 Lynparza for metastatic serous endometrial cancer. 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

At issue is Zolpidem Tartrate 12.5 milligram tablets prescribed for insomnia. 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.The documentation submitted supports you requested Zolpidem Tartrate. 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 Zolpidem Tartrate. There are no medical records to support you suffer from insomnia. 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 Panzyga 10 gram/100 milliliter prescribed for rheumatoid arthritis and Sjogren 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Panzyga to treat your rheumatoid arthritis and Sjogren syndrome. 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 Panzyga.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alosetron 1-milligram Tablet to treat short bowel syndrome. 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

At issue is Nuedexta 20-10 milligram capsule prescribed daily for pseudobulbar affect. 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 records submitted at the reconsideration level.The medical records show the doctor prescribed Nuedexta 20-10 milligram capsule to treat the enrollees condition. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollee was evaluated by the prescriber and a diagnosis of pseudobulbar affect was confirmed. 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 Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ranolazine 50 milligram extended release tablet prescribed 2 tablets twice daily for coronary artery disease. 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. Ranolazine 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

You requested Erythromycin 500 milligram tablet prescribed for chronic pancreatitis. The Part D plan denied your 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 prescriber statement shows Erythromycin was prescribed to treat chronic pancreatitis. 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 Erythromycin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nitro-Bid 2% ointment prescribed to treat osteoarthritis, Raynauds syndrome, and systemic sclerosis. 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 Nitro-Bid 2% ointment to treat osteoarthritis, Raynauds syndrome, and systemic sclerosis. However, the use of the requested drug to treat the provided diagnosis is an off-label use. Medicare approved compendia do not support the use of this drug for your conditions.A physician reviewed your appeal and determined that the plan is not required to cover Nitro-Bid 2% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tymlos 80 microgram/dose pen injector prescribed for 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 your doctor prescribed Tymlos to treat your osteoporosis. 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 Tymlos.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Testosterone 1.62 % patch prescribed for hypogonadism. The Part D plan denied the request.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.The medical records show the doctor prescribed Testosterone 1.62 % patch to treat the enrollees hypogonadism. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollee had two low pre-treatment serum total testosterone levels. 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 Testosterone 1.62 % patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Dupixent 300 milligram/2 milliliter pen injector prescribed for atopic 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. 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 Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ajovy 225 milligrams per 1.5 milliliters auto-injector prescribed to inject every month by subcutaneous route to treat migraine 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.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 Ajovy 225 milligrams per 1.5 milliliters auto-injector.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Prevymis 480-milligram tablet to treat cytomegalovirus infection. 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 indicated why all formulary alternatives required by the plan including Ganciclovir and Foscarnet would likely not be as effective as the requested drug for Ganciclovir-resistant cytomegalovirus infection, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the Plans formulary coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.