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

At issue is a request for coverage of Paliperidone 1.5 milligram tablet ER prescribed for adult deficit hyperactivity disorder and obsessive compulsive disorder. 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 documentation shows Paliperidone was prescribed to treat adult deficit hyperactivity disorder and obsessive compulsive disorder. However, the Medicare approved compendia do not support the use of this drug for the enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Paliperidone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cosentyx 300 milligram solution auto-injector prescribed for psoriasis vulgaris. 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. 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. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan 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 formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.A physician reviewed your appeal and determined that the plan is not required to Cosentyx.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cimzia 400-milligrams/2-milliliters (200-milligrams/milliliter X 2) Syringe Kit to treat rheumatoid arthritis. 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.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 the appeal and determined that the requested drug is not eligible for Part D coverage.