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

You requested Ibandronate Sodium 150 milligram tablet prescribed daily for the prevention of osteoporosis secondary to end stage renal 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. According to Medicare rules, the requested drug cannot be approved for separate payment under Part D when it's for treatment of a patient who is receiving dialysis. Medicare records show the enrollee is actively receiving dialysis. Therefore, the Ibandronate Sodium must be billed by the renal dialysis facility. We determined that the plan is not required to cover the Ibrandronate Sodium. Please submit your request for this drug through the dialysis provider.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gralise 600 milligram oral tablet. 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 Gralise to treat type II diabetes mellitus with diabetic polyneuropathy. The Medicare approved compendia supports the use of this drug for this condition. However, no medical records were submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover Gralise.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Boostrix suspension 5/2.5/18.5/LF-MCG/0.5 prescribed for vaccination. 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 plan submitted documentation that shows you were still in the deductible stage of the Part D benefit when you were administered the vaccination at your physician's office. Your plans Evidence of Coverage states that you are responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined the amount you paid was applied to your deductible and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets. 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.Xifaxin is included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.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 Dupixent 300 milligram/2 milligram solution prefilled syringe prescribed for eosinophilic asthma. 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 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. Your medical records show your doctor prescribed Dupixent to treat your eosinophilic asthma. 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 Dupixent. 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 prescribed Stelara 90 milligram per milliliter syringe. 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 Stelara to treat your plaque psoriasis. 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 Stelara. 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

You requested Xeljanz 5 milligram oral tablet prescribed daily for lichen planopilaris. 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 Xeljanz to treat your lichen planopilaris as known as frontal fibrosing alopecia. 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 Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dextroamphetamine Sulfate extended-release 15 milligrams capsule extended-release 24-hour prescribed to treat hypersomnia. 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 additional information regarding your condition. We also asked for additional medical records or other documentation to show why you need this medication. We did not receive the requested documentation.According to DRUGDEX, Dextroamphetamine Sulfate is indicated for the treatment of attention deficit hyperactivity disorder (ADHD) as an integral part of a total treatment program, typically including psychological, educational and social measures. The psychiatric clinic note dated two years ago shows a diagnosis of attention deficit hyperactivity disorder, but fails to document if a total treatment program was initiated. There were no updated psychiatric clinic notes submitted. The prescribers clinic note dated January 6, 2021, shows Dextroamphetamine Sulfate extended-release 15 milligrams capsule extended-release 24-hour was prescribed for hypersomnia and does not include the diagnosis of ADHD. Additional medical records have not 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 Dextroamphetamine Sulfate extended-release 15 milligrams capsule extended-release 24-hour.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a prior authorization for Eszopiclone 2 milligram tablets. 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 to support a prescribed diagnosis. A request for information was sent to the prescriber; 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

You requested Armodafinil 150 milligram tablets prescribed to treat fatigue related to multiple sclerosis. 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 Armodafinil 150 milligram tablets to treat fatigue related to multiple sclerosis. 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 Armodafinil 150 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100-62.5-25 dry powder inhaler prescribed daily. 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. Trelegy Ellipta 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

You requested Nuzyra 150 milligram tablets prescribed to treat severe lung obstruction and non-tuberculous mycobacterial pulmonary disease from Mycobacterium abscessus. 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 Nuzyra 150 milligram tablets to treat severe lung obstruction and non-tuberculous mycobacterial pulmonary disease from Mycobacterium abscessus. 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 Nuzyra 150 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a prior authorization and a tiering exception for Xifaxan 550 milligram tablets. 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 medical records to support a prescribed diagnosis. A request for information was sent to the prescriber; 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 Acthar gel 400 units per 5 milliliter vial prescribed daily for rheumatoid arthritis. 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. The prior authorization requirements were not addressed because the requested drug is not listed on the plans formulary and therefore not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Acthar.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lasix 20 milligram tablets prescribed for unspecified heart failure. 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 medical records or a supporting statement. A request for information was sent to the prescriber; 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 prior authorization request for Doxepin Hydrochloride 25 milligram capsules prescribed for depression with anxiety. 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 on hand does not include a physician supporting statement. A request for information was sent to the prescriber; however, no further documentation was received. The documentation received does not support that the enrollee satisfies 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

You requested Nulojix 250 milligram powder solution prescribed following a lung transplant. The Part D plan denied the 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 Nulojix at issue is prescribed following a Medicare covered transplant. This is eligible for coverage under Part B. Your plan does not offer supplemental (additional) coverage for this biologic. If you purchased biologics that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the biologic. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Heparin Sodium 20,000 units per milliliter vial, prescribed 42,000 units subcutaneous injection one time, then 32,000 units every 12 hours until the international normalized ratio (INR) is greater than two for atrial fibrillation. 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 determined that the drug is not eligible for Part B coverage. The drug is being given as a bridge while Warfarin is held for the diagnosis of atrial fibrillation and not end stage renal disease. Therefore, the drug can be considered for payment under the Part D benefit. The medical records show the doctor prescribed Heparin Sodium to treat the enrollees atrial fibrillation. The following citation was referenced in DrugDex, a Medicare approved compendia, and supports the use of this drug for your condition: Heparin is indicated for prophylaxis and treatment of thromboembolic complications associated with atrial fibrillation.A physician reviewed this appeal and determined that the plan is required to cover Heparin Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch for chronic back 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. The documentation shows your doctor prescribed Lidocaine 5% patch to treat your chronic back pain. 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrocortisone Acetate 25 milligram suppository prescribed for Barrett's esophagus and constipation. 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 Hydrocortisone Acetate is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover Hydrocortisone Acetate. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nitazoxanide 500 milligram oral tablet prescribed twice daily for 10 days. 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 Nitazoxanide to treat helicobacter pylori. 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, as ordered, is not being used for a medically accepted indication. 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 Nitazoxanide. The quantity limit exception was not addressed because the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine Hydrochloride 2 milligram sublingual tablets prescribed for chronic pain. 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 Buprenorphine Hydrochloride for chronic pain. The Medicare approved compendia do not support the use of the drug at issue for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed. Of note, you further requested a quantity limit exception; however, as the drug has not been approved, a quantity limit exception cannot be granted.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 Mycophenolate Mofetil 500 milligram tablets prescribed following a kidney transplant. The Part D plan denied the 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 Mycophenolate Mofetil at issue is prescribed following a Medicare covered transplant. This is eligible for coverage under Part B. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pramipexole Dihydrochloride 1.5 milligram tablet prescribed three tablets daily for Parkinsons disease. The Part D plan denied the request for a tiering exception.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. Pramipexole Dihydrochloride 1.5 milligram tablet is a generic drug on Tier 2 of the plans formulary. There are no generic 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: Favorable

You requested Tadalafil 40 milligram tablet prescribed for pulmonary hypertension, right heart failure due to pulmonary hypertension and congestive heart failure. 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 Tadalafil to treat your pulmonary hypertension, right heart failure due to pulmonary hypertension and congestive heart failure. The Medicare approved compendia support the use of this drug for your conditions. Although a pulmonary wedge pressure is not reported, the combination of elevated pulmonary artery pressures associated with right ventricular dilation, is consistent with pulmonary artery hypertension.A physician reviewed your appeal and determined that the plan is required to cover Tadalafil.