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

At issue is Hetlioz 20 milligram capsule prescribed for non-24-hour sleep wake disorder. 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 establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, medical records supporting that medically accepted indication are required. These records were requested from the prescriber, and we did not receive information that could answer these medical necessity issues.  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 Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 100 milligram tablets prescribed for your medical condition. 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.At reconsideration, documentation indicates the prescriber ordered Modafinil for daytime somnolence. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Hetlioz 20 milligram capsules prescribed for the management of circadian rhythm sleep disorder free run type, non-24-hour sleep-wake disorder. 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 plan has prior authorization requirements that must be met before coverage of this medication will be approved. 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 Hetlioz 20-milligram capsule to treat circadian rhythm sleep disorder, free running type (Non-24) and blindness, both eyes. The 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.To support this diagnosis, the prescriber provided no medical records. 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 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 Opsumit 10 milligram tablets prescribed for primary pulmonary hypertension. 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. Opsumit is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all the formulary alternatives that are included in the plan to treat the enrollees condition 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 a tiering exception request for Myrbetriq 50 milligram extended release tablets 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 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.Myrbetriq is a brand drug on Tier 4 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch. At initial determination and redetermination the diagnoses of pain in right wrist and acute back pain were given. 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. At the reconsideration level, a diagnosis of vertebral compression fractures was added. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records and other documentation to show why the medication is needed. We did not receive the documentation requested.The documentation indicates that the doctor prescribed Lidocaine to treat the enrollees right wrist pain and acute back pain/vertebral fracture. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition(s). A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lupron Depot 22.5 milligram 3 month kit prescriber for malignant neoplasm of the prostate. The Part D plan denied the request and indicated it has been approved under Part B. 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 also researched Medicare regulations and Medicare approved compendia.The prescriber indicates the medication is shipped from the pharmacy to the physicians office on behalf of the patient and should be under Part D benefits. Part D eligible drugs are drugs self-administered by the enrollee or can also include drugs picked up at the pharmacy by the enrollee and taken to the physicians office for administration. The drug is not considered a Part D eligible drug and was appropriately reviewed under Part B benefits.  A physician reviewed your appeal and determined that the plan is not required to cover Lupron Depot under Part D drug benefits.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calquence 100-milligram Capsule. At initial determination and redetermination the diagnosis of recurrent Non-Hodgkins Lymphoma was given. 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.At reconsideration a diagnosis of other non-follicular lymphoma, lymph nodes of axilla and upper limbs was given. The use of the requested drug to treat the provided diagnoses are off-label uses. 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.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 5% patch prescribed for dorsalgia. 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 medication is needed. We did not receive the documentation requested.The documentation shows Lidocaine was prescribed for dorsalgia. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Qbrexza 2.4% towelette cloths. 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 submitted to the plan indicates that Qbrexza cloths have been prescribed for hyperhidrosis of the forehead and cheeks. 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. It has been noted in an unsigned statement, which has been submitted at reconsideration, that the enrollee uses the Qbrexza medicated towelettes on the hands and underarms, as well. However, no medical records have been submitted to confirm this additional information. Therefore, the submitted documentation does not do not validate that the drug is being prescribed for a medically accepted indication. As such, the drug 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Diclofenac Epolamine 1.3% topical 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. The medical records indicate that Diclofenac Epolamine patches have been prescribed for the management of low back and radicular leg pain due to the presence of chronic conditions, such as lumbar spinal stenosis with neurogenic claudication, history of healed traumatic fractures from falls, and history of right hip replacement. 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta 50 milligram tablet prescribed for chronic pain. 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 prescriber indicates they prescribed Nucynta to treat acute on chronic low back pain. The medical records support this condition and this is a medically accepted indication for the use of Nucynta immediate release tablets. However, Nucynta immediate release tablets are not on the plans formulary. 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 Nucynta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy tablets prescribed for migraine, unspecified, not intractable, without status migrainosus. 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 prescriber indicates that the enrollee needs acute/abortive treatment for migraines due to disability from migraines. The medical records provided do not support acute migraines. Medicare approved compendia do not support the use of this drug for the enrollees condition.  A physician reviewed your appeal and determined that the plan is not required to cover Ubrelvy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Diclofenac Sodium 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.The documentation initially submitted to the plan indicates that Diclofenac Sodium has been prescribed for the treatment of diabetic neuropathy. 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. The prescriber has noted in a statement, which has been submitted at reconsideration, that the enrollee also has underlying osteoarthritis affecting the hands and knees. However, no medical records have been submitted to confirm this additional diagnosis. Therefore, the submitted documentation does not validate that the drug is being prescribed for a medically accepted indication. As such, drug 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick solution auto-injector 140 milligram/milliliter prescribed for atherosclerotic heart disease of native coronary artery 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 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 the enrollees condition. We also asked for medical records and other documentation to show why the medication is needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. 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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick solution auto-injector 140 milligram/milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stelara 45 milligram/0.5 milliliter prefilled syringe prescribed for pyoderma gangrenosum. 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 submitted documentation indicates the prescriber ordered Stelara for pyoderma gangrenosum. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Gammagard Liquid 10% (10 gram per 100 milliliter) solution for intravenous infusion. 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 Gammagard Liquid has been prescribed for the treatment of statin-induced myopathy. 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Benicar HCT 40-12.5 milligram tablets prescribed for hypertension. 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. Benicar HCT is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all the formulary alternatives that are included in the plan to treat the enrollees condition 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 Benztropine Mesylate 1 milligram tablet twice daily prescribed for extrapyramidal symptoms. 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.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 did not receive the documentation requested.The doctor prescribed Benztropine Mesylate to treat the enrollees extrapyramidal symptoms. 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 Benztropine Mesylate. 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 Latanoprost 0.005% eye drops prescribed as 7.5 milliliters per 30 days to treat primary open-angle glaucoma. 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. Your prescriber requests Latanoprost 0.005% eye drops with a quantity of 7.5 milliliters per 30 days to treat primary open-angle glaucoma. However, the plan has a quantity limit of 2.5 milliliters per 30 days. The documentation does not support a medical necessity for an exception to the plans quantity limit.  A physician reviewed your appeal and determined that the plan is not required to cover Latanoprost 0.005% eye drops with a quantity of 7.5 milliliters per 30 days.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epogen 10000 units/milliliter vial prescribed for a kidney transplant recipient. 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. Medicare records show the enrollee had a kidney transplant while covered under Medicare Part A. Drugs used to prevent transplant rejection may be covered under Part B when the transplant was paid for by Medicare. This drug is not eligible for coverage under Part D drug benefits. We determined that the plan is not required to cover Epogen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 200 milligram tablet prescribed for fatigue related to multiple sclerosis. 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. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records and other documentation to show why the medication is needed. We did not receive the documentation requested.The medical records show the doctor prescribed Modafinil to treat the enrollees fatigue related to multiple sclerosis. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for the enrollees condition: Interestingly, in a 9-week, phase 2, single-blind, 2-center, pilot study (n=72), 2 weeks of modafinil 200 milligram daily significantly improved fatigue severity scale scores compared with placebo in patients with multiple sclerosis.However, 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 Modafinil. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.