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

At issue is Lidocaine 5% adhesive patch prescribed daily for post-mastectomy pain syndrome and intercostal neuralgia. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Lidocaine 5% adhesive patch to treat the enrollees post-mastectomy pain syndrome and intercostal neuralgia. However, the 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 Lidocaine 5% adhesive patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Estradiol 0.05 milligram per 24 hour patches. 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. Estradiol 0.05 milligram per 24 hour patch is a generic drug on Tier 4 of the plans formulary.There are no generic 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

You requested Ipratropium-albuterol .5-3(2.5) milligram/3 milliliter solution prescribed for unknown diagnosis. The Part D plan denied your requestWe 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 record shows Ipratropium-albuterol is being administered through a nebulizer for use in the home setting. Medicare Part B covers supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to reimburse you for the Ipratropium-albuterol. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta 75 milligram tablets prescribed to treat fibromyalgia and chronic back pain.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  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. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine 10 milligram tablet to treat muscle spasm associated with chronic musculoskeletal conditions.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  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. The prescriber provided medical records which documented that the enrollee has muscle spasm associated with sciatic pain, chronic low back pain, lumbar disc disease, lumbar spinal stenosis, and a history of L4-L5 back surgery. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Methylphenidate Hydrochloride 10 milligram tablets. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Methylphenidate Hydrochloride has been prescribed for the treatment of refractory bipolar depression. 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 your appeal and determined that the plan is not required to cover Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Evenity 20 milligram tablets 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. We received a statement from your doctor that Evenity was prescribed to treatment osteoporosis. 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 documentation does 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 Evenity.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Praluent Pen Injector 75 milligram/milliliter prescribed to treat hyperlipidemia. 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 prescriber indicates the enrollee has tried Atorvastatin 40 milligram and Tricor 145 milligram with no improvement. However, there is no documentation that the enrollee had tried the high intensity statin and Ezetimibe for at least 8 continuous weeks. The prior authorization requirements were not met. A physician reviewed your appeal and determined that the plan is not required to cover Praluent Pen Injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Arava 20 milligram tablets prescribed daily for rheumatoid arthritis. The Part D plan did not make a decision.We received the case to perform an independent and de novo review. To make our decision, we read 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.We asked the 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 medical records and included them in our review. However, we did not receive a prescriber statement.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 Arava.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nourianz 20 milligram tablets prescribed for Parkinson's disease. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any 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 Nourianz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Metaxalone 800 milligram tablets. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Metaxalone has been prescribed for the treatment of chronic tension headaches and muscle spasms associated with multiple sclerosis. 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 conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover Metaxalone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pennsaid 2% solution prescribed to treat right knee pain. 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 Pennsaid 2% solution to treat right knee 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 Pennsaid 2% solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Reyvow 50 milligram tablet prescribed for migraine without aura, not intractable, without status migrainosus. 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. Reyvow is a brand name drug on Tier 4 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 a request for coverage of Diclofenac Epolamine 1.3% patches. 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 Diclofenac Epolamine has been prescribed for chronic right foot and heel pain due to plantar fascial fibromatosis. 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 your appeal and determined that the plan is not required to cover the Diclofenac Epolamine 1.3% patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Entresto 24-milligram/26-milligram tablets to treat unspecified systolic heart failure. 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.Entresto is a brand drug on Tier 3 of the plans formulary. There are no brand 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 a request for coverage of Humira 80 milligram and 40 milligram subcutaneous injection pens prescribed for plaque psoriasis. 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. 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 Lidocaine Patch 5% prescribed for cervical brachial 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. Your prescriber indicated that Lidocaine Patch 5% is prescribed to treat pain under your left arm, left shoulder, and neck areas. 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 Patch 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Voltaren 1% gel. 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.While the prescriber has noted at reconsideration that the enrollee has a diagnosis of osteoarthritis, the submitted progress notes show that the Voltaren gel was prescribed for the treatment of chronic low back pain. 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 your appeal and determined that the plan is not required to cover Voltaren 1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alphagan P 0.1 percent ophthalmic solution prescribed for primary open-angle glaucoma. 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. Alphagan P 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 Spiriva Respimat 2.5 microgram/actuation prescribed for chronic obstructive pulmonary disease. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your prescriber indicates you have tried Qvar for this condition. However, there is no supporting evidence that all the plans formulary, alternative drugs, have been tried.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 Spiriva Respimat.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil 100 milligram tablet. The Part D plan denied your request. We performed and 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 Sildenafil because it was used to treat sexual or erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Benztropine Mesylate 2 milligram tablets. The Part D plan denied the request because the plans prior authorization requirements were not met. 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 medical records submitted at reconsideration indicate that Benztropine Mesylate has been prescribed for a movement disorder status post arteriovenous malformation. 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 your appeal and determined that the plan is not required to cover Benztropine Mesylate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Repatha SureClick 140 milligram per milliliter subcutaneous auto injection pen prescribed for coronary artery disease and hyperlipidemia. 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.Repatha SureClick is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives included in the plan to treat the noted conditions 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

At issue is Pramipexole Dihydrochloride 0.5 milligram tablets prescribed 3 times a day for Parkinsons 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. Pramipexole Dihydrochloride is a generic drug on Tier 2 of the plans formulary. There are no generic 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 Pradaxa 150-milligram capsule to treat deep vein thrombosis, prophylaxis. The Part D plan denied the request stating that the provided diagnosis of hypercoagulable state is a non-medically accepted indication. Therefore, a tiering exception could not be allowed.  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.Your prescriber ordered Pradaxa to treat your deep vein thrombosis, prophylaxis, which is a medically accepted indication. Pradaxa is a brand drug on Tier 4 of the plans formulary. However, there are no brand 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

You requested Lidoderm 5 percent patch prescribed for periumbilical hernia and periumbilical abdominal pain due to surgery/incisional hernia without obstruction. 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 Lidoderm 5 percent patch to treat your periumbilical hernia and periumbilical abdominal pain due to surgery/incisional hernia without obstruction. 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 Lidoderm 5 percent patch.