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

You requested Tabrecta 200 milligram tablets prescribed four times daily for metastatic gastric 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 Tabrecta for metastatic gastric cancer with a MET 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 formulary exception request for Afinitor 5 milligram tablets prescribed for metastatic carcinoma. 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 Afinitor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine Patch 1.3% prescribed for unspecified rotator cuff tear or rupture of right shoulder, intervertebral disc disorders with myelopathy and lumbar region and sciatica. 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, your physician has not indicated why all 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 Diclofenac Epolamine Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate (2.5 milligrams per 3 milliliter) 0.083 percent nebulizer solution prescribed as directed via nebulizer for moderate persistent asthma uncomplicated. 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 record shows the doctor prescribed Albuterol Sulfate for moderate persistent asthma uncomplicated. However, this drug is eligible for coverage under Medicare Part B. Medicare Part B covers this drug for moderate persistent asthma uncomplicated, when used with a nebulizer in the home (or in an assisted living facility). Medicare Part D cannot pay for drugs that are covered by Medicare Part B.We reviewed your appeal and determined that the plan is not required to cover Albuterol Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine-Dextroamphetamine ER 10 milligram capsules 60 per 30 days, prescribed for attention deficit hyperactivity disorder. The Part D plan denied your request for the quantity requested.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 you prescribed Amphetamine-Dextroamphetamine ER 10 milligram capsules to treat the enrollees attention deficit hyperactivity disorder, which is a medically accepted indication. However, the medical records do not support why an exception to the plans quantity limit is medically necessary. There are also alternative drug dosages available on the formulary that have not been addressed.A physician reviewed your appeal and determined that the plan is not required to cover Amphetamine-Dextroamphetamine ER 10 milligram capsules 60 per 30 days, as the request exceeds the number of doses of that formulation, 30 per 30 days, allowed by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablet prescribed one tablet twice a day for 90 days for irritable bowel syndrome with diarrhea. 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. Your medical records show your doctor prescribed Xifaxan to treat your irritable bowel syndrome with diarrhea. 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 Xifaxan. The medical records do not support you are currently experiencing symptoms. 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: Favorable

You requested Procrit 10000 units/milliliter prescribed for anemia secondary of chronic kidney 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 plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. For enrollees not on dialysis, the plan requires a pre-treatment hemoglobin level less than 10 grams per deciliter. The documents submitted include laboratory studies with a hemoglobin of 9.3 grams/deciliter. The plans prior authorization requirements were met. A physician reviewed your appeal and determined that the plan is required to cover Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica 300 milligram capsules prescribed for heredity and idiopathic neuropathy, and pain. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your prescriber indicates you have been on this medication for months. 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, your physician has not indicated why all 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 Lyrica.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a formulary exception for Proair HFA 90 microgram inhaler prescribed for sarcoidosis of lung. 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 Proair HFA for sarcoidosis of lung. The submitted documentation indicates your diagnosis should be asthma. There were no medical records or supporting statement on file. A request for information was sent to your doctor; however, no further documentation was received. As it cannot be determined 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 a request for coverage of Elmiron 100 milligram capsules, 270 capsules per 90 days, prescribed for interstitial cystitis. 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. Elmiron is included in the Specialty Tier (Tier 5) of the plans formulary. Drugs in the Specialty Tier are limited to a recurring 30-day supply. An exception to the quantity limit criteria has not been met. A physician reviewed the appeal and determined that the plan is not required to cover a 90-day supply of Elmiron.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humira 40 milligram/0.8 milliliter syringe kit prescribed for cardiac sarcoidosis. 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 Humira syringe kit prescribed for cardiac sarcoidosis. The Medicare approved compendia do not support the use of the biologic at issue for your conditions. As the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humulin R U-500 500 milliliter vial 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.Humulin R U-500 is on the specialty tier of your plans formulary. Biologics that are on the plans specialty tier are 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 Tymlos Solution Pen-Injector 80 micrograms prescribed for age-related osteoporosis in a male enrollee. 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 the enrollee has genetically proven osteogenesis imperfect type IV and severe osteoporosis complicated by multiple fractures. However, 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: Unfavorable

You requested Omeprazole 20 milligram Capsule prescribed for kidney transplant status and essential hypertension. 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 the enrollee has a history of gastrointestinal reflux disease and ileus. However, the medical records submitted do not support the diagnosis of gastrointestinal reflux disease. Medicare approved compendia do not support the use of this drug for any diagnoses shown on the medical records submitted.  A physician reviewed your appeal and determined that the plan is not required to cover Omeprazole.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Fenofibric Acid 135 milligram DR capsules prescribed for mixed hyperlipidemia. 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. The submitted documentation did not include a supporting statement or medical records. A request for information was sent to your physician. Your physician submitted a supporting statement and medical records. 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 Fenofibric Acid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Opsumit 10 milligram tablets prescribed daily for pulmonary arterial hypertension. 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 Opsumit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligram/milliliter pen injector prescribed as directed for 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 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

At issue is a request for coverage of Acetylcysteine 20% solution. 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 Acetylcysteine 20% solution has been prescribed to be used for the irrigation of a urinary Indiana pouch to avoid clogging of the pouch with mucus and/or stones. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the Acetylcysteine 20% solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Cimzia 200 milligram/milliliter prefilled syringe kit prescribed for plaque psoriasis. 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. 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 Cimzia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Clobetasol Propionate 0.05% lotion prescribed for plaque psoriasis. 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 or medical records. A request for information was sent to your physician. No further documentation was received to support 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 Clobetasol Propionate.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nubeqa 300 milligram tablet prescribed for metastatic castration resistant 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. Your medical records show your doctor prescribed Nubeqa 300 milligram tablet to treat your metastatic castration resistant prostate cancer. The medical records submitted indicate that you are not a candidate for any further metastatic castration resistant prostate cancer treatment options. According to an open label phase 1 dose escalation and randomized phase 2-dose expansion trial published by Lancet Oncology, a Medicare approved journal, Nubeqa suppressed disease and had a favorable safety profile in patients with progressive metastatic castration resistant prostate cancer. Therefore, this is a medically accepted indication. In addition, your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided shows an exception to the prior authorization criteria can be made.An oncologist reviewed your appeal and determined that the plan is required to cover Nubeqa 300 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Phenelzine Sulfate 15 milligram tablets prescribed daily 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.Phenelzine Sulfate is a generic drug on Tier 3 of the plans formulary. The supporting statement from the prescriber does not address why all alternative lower-tier medication on the plans formulary would not work for you. All drugs on lower tiers have not been tried. 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 Clonidine Hydrochloride 0.1 milligram ER tablets prescribed for attention deficit hyperactivity disorder in an adult. 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 Clonidine Hydrochloride ER tablets for attention deficit hyperactivity disorder in an adult. 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 the Lidocaine 5% patch. 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 providing a diagnosis and to show why you need this medication. We did not receive the requested documentation.The appeal request is for the Lidocaine 5% patch. No medical records have been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clobetasol 0.05% ointment prescribed for psoriasis. 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. 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 Clobetasol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sure Click 140 milligrams/milliliter prescribed as directed for coronary artery disease involving native coronary artery of native heart without angina pectoris. 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.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.Your medical records show your doctor prescribed Repatha Sure Click to treat your coronary artery disease involving native coronary artery of native heart without angina pectoris. 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 Sure Click.