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

You requested Repatha Sureclick 140 milligrams/milliliter prescribed for hyperlipidemia with atherosclerosis. 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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We received the documentation and included it in our review.The medical records show you prescribed Repatha Sureclick 140 milligrams/milliliter to treat the enrollees hyperlipidemia with atherosclerosis. The Medicare approved compendia do support the use of this drug for this condition.The plan requires evidence of conditions that include peripheral artery disease, for coverage of hyperlipidemia with atherosclerotic cardiovascular disease before they will cover the requested drug. The prescriber statement indicates that the enrollee has peripheral artery disease. However, the medical records submitted do not adequately support that the enrollee has peripheral artery disease as mentioned in the prescribers statement. 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 Sureclick 140 milligrams/milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram tablet prescribed as directed to treat circadian rhythm sleep disorder, free running type. The Part D plan autof-forwarded the request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the plans prior authorization criteria. We did not receive a response. Therefore, based upon the current record, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the Hetlioz.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Strattera 40 milligram oral capsule prescribed daily for attention deficit hyperactivity disorder. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration 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 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.Your physician submitted a supporting statement and medical records. The medical records show the physician had prescribed Strattera to treat your attention deficit hyperactivity disorder. The following citation was referenced in DrugDex, a Medicare approved compendium, and 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, you tried the preferred generic drug Atomoxetine and experienced adverse effects such as blisters on the lips, which resulted in the need for an epi-pen. A physician reviewed your appeal and determined that the plan is required to cover Strattera.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vascepa 1 gram capsule to treat hypercholesterolemia. 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 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.A request was submitted to the prescriber to provide a diagnosis and supporting medical records. The reply from the prescriber included a diagnosis of hypertriglyceridemia. However, medical records were not received. It cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Skyrizi 150-milligrams/1.66milliliter (75-milligrams/0.83 milliliter x 2) subcutaneous injection to treat plaque psoriasis. 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.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a direct reimbursement for Colesevelam 625 milligram tablets prescribed for bile acid induced diarrhea. 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 Colesevelam for bile acid induced diarrhea. The Medicare approved compendia do not support the use of the drug for your condition. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise 300 milligram tablet prescribed as directed to treat epilepsy and chronic pain syndrome.  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 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 initially provided the diagnosis of chronic pain syndrome.  The prescriber clarified the diagnosis as epilepsy in the request for consideration. Medical records were provided which substantiate that the requested drug has been prescribed for both the treatment of chronic pain syndrome and epilepsy.  The use of the requested drug to treat the provided diagnoses 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 these conditions.  Therefore, the requested drug is not eligible for coverage under Medicare Part D
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Pregabalin 50 milligram capsules. 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 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 Pregabalin has been prescribed for a chronic persistent cough. 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 Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tretinoin 0.025 percent cream prescribed as directed for discoid lupus erythematosus with painful skin ulcers on the anogenital area, thighs, and lower back. 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. We also researched Medicare systems and reviewed the enrollment data available. 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 drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and determined  that the plan is not required to cover Tretinoin.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Vyvanse 40 milligram capsule to treat attention deficit disorder. 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.The following citation in Micromedex, a Medicare approved compendium, supports the use of the requested drug for the enrollee's condition: Vyvanse is approved for the treatment of attention deficit hyperactivity disorder in adults, adolescents, and children six years or older. The medical records show the enrollee has had a seven year history of attention deficit disorder. The documentation satisfies the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Meclizine 25-milligram tablet to treat the enrollees vertigo. The case was auto-forwarded by the plan.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.Meclizine is a generic drug on Tier 3 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 Testosterone Cypionate 200 milligram/milliliter solution prescribed for low testosterone levels. 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 indicates your doctor prescribed Testosterone Cypionate for low testosterone levels. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Diclofenac Epolamine 1.3% 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 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 also researched Medicare systems and reviewed the enrollment data available.While your doctor has stated that the Diclofenac Epolamine patches have been prescribed for acute pain due to a lower back strain, your claims history shows that you have paid consecutive claims for Diclofenac Epolamine patches for more than one year. This would indicate that the pain is related to a chronic condition. The Medicare approved compendia do not contain any citations to support the use of Diclofenac Epolamine for chronic pain conditions. Your doctor has not submitted any medical records to validate that the Diclofenac Epolamine patches are being prescribed for acute pain. Due to the conflicting information available, it is not possible to determine if the Diclofenac Epolamine patches are being prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover the Diclofenac Epolamine patches.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 250 milligram prescribed one capsule twice daily for post kidney transplant status. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited reconsideration 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.Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules. Medicare records support you underwent a kidney transplant on July 9, 2009. Therefore, this drug is eligible for coverage under Medicare Part B. We determined that the plan is not required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nitrofurantoin Macrocrystalline 50 milligram capsule to treat urinary tract infection(s), prophylactically. 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and medical records have not been provided. 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

You requested a cost tiering exception for Nifedipine ER 90 milligram tablets prescribed for hypertension, stage 3 chronic kidney disease, and history of renal transplant. 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.Nifedipine ER is a generic drug on Tier 3 of the plans formulary. The prescriber has not sufficiently addressed why all of the generic drugs on the lower tiers of the plans formulary to treat the enrollees condition have been tried and failed, or are contraindicated. A physician reviewed your appeal and determined that the plan is not required to cover the Nifedipine ER at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cayston 75 milligram inhalation solution prescribed for chronic infection with Haemophilus influenza. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation indicates your doctor initially prescribed Cayston for your diagnosis of bronchiectasis. The medical records submitted support the drug was prescribed for chronic infection with Haemophilus influenza. However, your plan has prior authorization criteria assigned to the drug at issue. You do not satisfy 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 Xiidra 5% eye drops prescribed for dry eye syndrome. 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 Xiidra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested an off-formulary exception for Guanfacine Hydrochloride 1 milligram extended release tablets prescribed for Tourette's syndrome, tics, developmental delays, agitation and autism. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration 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 prescriber initially provided the diagnosis of tics, developmental delays, agitation and autism.  In the request for reconsideration, the prescriber changed the diagnosis to Tourette's syndrome. The records provided do not support a diagnosis of Tourette's syndrome.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% ointment prescribed for chronic pain, cervical spondylosis, and lumbar facet syndrome. 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 indicates your doctor prescribed Lidocaine ointment for chronic pain, cervical spondylosis, and lumbar facet syndrome. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gammagard 10% liquid vial prescribed for use with an infusion pump for the treatment of common variable immunodeficiency. 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 Gammagard is being administered to the enrollee via external infusion pump that is used in the home. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment, if the equipment used in the patients home. Payment may be made for supplies necessary for the effective use of DME, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. We determined that the Medicare Part D plan is not required to cover Gammagard. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Votrient 200 milligram tablets prescribed for a recurrent glioblastoma. 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 indicates your doctor prescribed Votrient for a recurrent glioblastoma. Your doctor prescribed the drug at issue based upon VEGF activity. However, the Medicare approved compendia do not support the use of this drug for your condition. 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 Symbicort 160/4.5 microgram aerosol inhaler prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no brand drugs of the same type on the lower cost sharing tiers. We received a reconsideration 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. Symbicort is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Genotropin 12 milligram/milliliter cartridge prescribed as directed for growth hormone deficiency. 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 you were prescribed Genotropin to treat your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided do not clearly show the coverage criteria has been met. The miscellaneous lab test submitted is not specifically identified and there is not information regarding what, if any, substance was used during the testing. There is not an order included regarding the specifics of the miscellaneous test. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover Genotropin.