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

At issue is Duxipent 300-milligrams/2-milliliters Pen Injector to treat pruritis prurigo and lichen simplex chonicus. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.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 Invega Sustenna 234 milligrams/1.5 milliliter injection prescribed for bipolar disorder, current episode manic severe with psychotic features and schizoaffective disorder. 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. This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. 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 Fluorometholone 0.1% ophthalmic drops prescribed for bilateral post-operative corneal transplant.   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.Fluorometholone ophthalmic drops is a generic drug on Tier 3 of the plans formulary.The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  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 is Amphetamine-Dextroamphetamine to treat multiple sclerosis related fatigue. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.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 a request for coverage of Amphetamine-Dextroamphetamine 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 Amphetamine-Dextroamphetamine has been prescribed for multiple sclerosis related fatigue. 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 Amphetamine-Dextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Cypionate 200 milligrams per milliliter for intramuscular injection prescribed for male hypogonadism. The Part D plan denied 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. During this review, a prescriber statement and supporting medical records were requested from the prescribing physician and received. During this review, a prescriber statement and supporting medical records were requested from the prescriber and received. However, 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 coverage for Ofev 100 milligram capsules prescribed for interstitial lung disease with progressive pulmonary fibrosis. 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 submitted documentation does not satisfy the plans criteria. The prescriber has not sufficiently addressed the plans criteria for coverage of the drug 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

You requested Tacrolimus 0.1 percent ointment for irritant dermatitis/unspecified contact dermatitis. 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 this medication. We did not receive the documentation requested.The documentation shows your doctor prescribed Tacrolimus to treat your irritant dermatitis/unspecified contact dermatitis. 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 Tacrolimus.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Oxycodone Acetaminophen 10-325 milligram tablet prescribed for pain associated with facet arthritis of lumbosacral region. 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 plan requires for coverage of Oxycodone Acetaminophen that certain drug combinations should be avoided when taken at the same time. The prescriber stated that Diazepam, a benzodiazepine, was  discontinued on 3/30/2021.  The prescriber states that you will not be kept on both an opioid and a benzodiazepine. Medical records from date of service 3/30/2021 were provided which documented that Valium was being discontinued.  The documentation includes clinical notes which satisfied the plan's coverage criteria. A physician reviewed your appeal and determined that the plan is required to cover Oxycodone Acetaminophen.  The physician reviewer also determined that an exception to the plans prior authorization requirements can be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Novolin 70/30 100 unit/milliliter vial prescribed for the enrollees condition. 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.Novolin 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

You requested a tiering exception for a Shingrix vial kit (shingles vaccine). 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. Shingrix is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Shingrix at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Indomethacin 25 milligram capsules. 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 Indomethacin has been prescribed for lumbar spondylosis with radiculopathy. 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 Indomethacin.
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 submitted medical records indicate that Diclofenac Sodium 1% gel has been prescribed for osteoarthritis of the hip and lumbar spine and for rheumatoid arthritis of that hands. 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 the Diclofenac Sodium 1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carisoprodol/Aspirin/Codeine 325/200/16 milligram tablet prescribed four times daily for cervical and lumbar degeneration of intervertebral discs. 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 Carisoprodol/Aspirin/Codeine to treat the enrollees cervical and lumbar degeneration of intervertebral discs. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed this appeal and determined that the plan is not required to cover Carisoprodol/Aspirin/Codeine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Amphetamine-Dextroamphetamine 5 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 Amphetamine-Dextroamphetamine has been prescribed for bipolar disorder. 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 Amphetamine-Dextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vascepa 1 gram capsule to reduce the risk of myocardial infarction, stroke, coronary revascularization and unstable angina in an enrollee with hypertriglyceridemia and a history of coronary artery disease and stroke.  The requested drug is not on the plans formulary.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 states the enrollees fasting triglyceride level is 205 and that the enrollee will continue to receive maximally tolerated statin therapy. Vascepa is not on the plans formulary.  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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue coverage for Otezla 30 milligram tablets prescribed for 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 supported 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 Corlanor 5 milligram tablet prescribed twice daily for inappropriate sinus tachycardia. 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 Corlanor to treat the enrollees inappropriate sinus tachycardia. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed this appeal and determined that the plan is not required to cover Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lotemax Suspension 0.5%. 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.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. In addition, 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 requested.At initial determination, the diagnosis of other corneal scars and opacities was given. However, the Medicare approved compendia do not support the use of this drug for this condition. As such, the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Lotemax suspension.
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 because the prior authorization requirements were not met, as the medication was prescribed for an indication not supported by Medicare references. 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 Sodium 1% gel has been prescribed for unspecified pain in the left knee. 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 Sodium 1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Firazyr 30 milligram oral tablets. 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 Firazyr to treat recurrent angioedema. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed as a prophylaxis, for the treatment of this 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 Firazyr.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Nystatin 100,000 units per gram powder. 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 submitted medical records indicate that Nystatin powder has been prescribed for a fungal infection to the groin. At reconsideration, the prescriber has clarified that the fungal infection is being caused by Candida. As outlined in the Medicare approved compendia, candidiasis infection of the skin is a medically accepted indication for the use of Nystatin powder. The plans only prior authorization requirement for the coverage of Nystatin powder is that the enrollee must be using the drug topically for the treatment active cutaneous or mucocutaneous candidiasis. As noted previously, the documentation supports that the Nystatin powder is being used topically for active cutaneous (skin) candidiasis at the groin area.Therefore, the documentation supports that the drug is being prescribed for a medically accepted indication and that the plans prior authorization requirement has been met. A physician reviewed your appeal and determined that the plan is required to cover the Nystatin powder.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Novolog 100 units/milliliter vial prescribed for diabetes mellitus. 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. Novolog 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 micrograms inhalation prescribed for the enrollees condition. 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.Spiriva Respimat 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 Hetlioz 20-milligram capsule to treat Non-24-Hour Sleep-Wake Disorder (Non-24). 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.The prescriber provided no medical records to support this diagnosis. 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.