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

You requested coverage for Harvoni 90/400 milligram tablets for 24 weeks of therapy in the treatment of chronic viral hepatitis C. The Part D plan denied coverage for 24 weeks of therapy, stating that The American Association for the Study of Liver Diseases Guidelines only recommends 12 weeks of treatment with Harvoni in those patients with Genotype 1a, compensated cirrhosis, who have previously failed treatment with interferon. Therefore, the plan approved coverage for 12 weeks of therapy with Harvoni from the date span of January 25, 2021, through May 6, 2021. 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. At reconsideration, the prescriber has requested an extension of the plans prior authorization approval of the 12-week treatment period of January 25, 2021, through May 6, 2021, stating that the enrollee did not start therapy with Harvoni until April 14, 2021. During this review, medical records were requested from the prescriber to validate the medication start date. The prescriber did not respond to the request.Without medical records to validate a late start date, the plans approval of the 12-week treatment with Harvoni for the period of January 25, 2021, through May 6, 2021, will not be extended. A physician reviewed your appeal and determined that the plan is not required to cover the Harvoni beyond the date of May 6, 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Topiramate 100 milligram tablets prescribed two times a day to treat 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. Your prescriber indicated that Topiramate is prescribed to treat your 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 Topiramate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablets prescribed two times a day to treat postural orthostatic tachycardia syndrome. 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. Your prescriber indicated that Corlanor is prescribed to treat postural orthostatic tachycardia syndrome. 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 your appeal and determined that the plan is not required to cover Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tetracycline Hydrochloride 500 milligram capsules, 60 capsules per 30 days prescribed to treat bullous pemphigoid.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Risperidone 0.25 milligram tablet prescribed for generalized anxiety 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 the doctor prescribed Risperidone to treat the enrollees generalized anxiety disorder. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Risperidone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% gel pump to treat testicular hypofunction.  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 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.  This drug requires very specific criteria to be met in order to be considered a medically accepted indication. The records provided do not indicate that male hypogonadism (testicular hypofunction) is the result of primary or hypogonadatropic hypogonadism. In addition, per the compendia, The safety and efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism.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 Apriso 375 milligram ER capsule prescribed for diverticular colitis. 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 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.. 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 adequately support why other drugs on the plans formulary, such as Balsalazide would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Apriso 375 milligram ER capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride Sublingual 8 milligrams prescribed once every 12 hours for chronic 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. Your prescriber indicated that Buprenorphine Hydrochloride Sublingual is prescribed to treat chronic pain. 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 your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride Sublingual.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 1 percent gel prescribed for chronic pain associated with 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 Diclofenac Sodium to treat your chronic pain associated with 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 Diclofenac Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 5 milligram oral capsule prescribed daily for nausea and vomiting due to gastroparesis. 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 Dronabinol to treat your nausea and vomiting due to gastroparesis. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20 milligram tablets prescribed daily for benign prostatic hyperplasia with lower urinary tract symptoms and malignant neoplasm of prostrate. 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 Sildenafil to treat your benign prostatic hyperplasia with lower urinary tract symptoms and malignant neoplasm of prostrate. However, the Medicare approved compendia do not support the use of this drug for your condition.   Also note that the prescriber was asked to provide directions for use and stated, 'One tablet prior to sexual activity.'  Medical records were requested and were not provided.A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Mayzent Starter Pack 0.25 milligram tablets prescribed for 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 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.Mayzent is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives included in the plan to treat the noted condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. Issues regarding needle phobia are not addressed in the medical record.  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 Diovan 160 milligram tablet prescribed twice daily for essential hypertension. 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. 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 Diovan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zolpidem Tartrate 5 milligram tablets prescribed to treat insomnia. 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. We also researched Medicare regulations and reviewed the enrollment data available. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plan requires that Doxepin 3 milligram or 6 milligram be tried or have an intolerance to the drug and the prescriber must acknowledge that the benefit of the therapy with this prescribed medication outweighs the potential risks for this patient. The prescriber did not send the medical records supporting that Doxepin was tried previously and no statement was made on the acknowledgement of the benefit of the therapy outweighs the potential risk in this older adult. Therefore, the prior authorization requirements were not satisfied.A physician reviewed your appeal and determined that the plan is not required to cover Zolpidem Tartrate.
Appeal type: Prescription Drug
Decision: Favorable

You requested Restasis Droperette 0.5% prescribed to treat keratonconjunctivitis sicca. 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. We also researched Medicare regulations and reviewed the enrollment data available. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plan has exclusion criteria of concurrent use of ophthalmic anti-inflammatory drugs or puntal plugs. The information submitted states that enrollee is not concurrently taking ophthalmic anti-inflammatory drugs or using punctal plugs. Therefore, the pre-authorization requirements were met.A physician reviewed your appeal and determined that the plan is required to cover Restasis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 200-62.5-25 inhaler prescribed for reactive airway disease/asthma. 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 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 Lidocaine Patch 5% prescribed for pain following a motor vehicle accident. 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. Your prescriber indicated that Lidocaine Patch 5% is prescribed to treat pain following a motor vehicle accident. 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 Patch 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 2 milligram sublingual tablets prescribed for chronic pain in multiple sites. 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. Your prescriber indicated that Buprenorphine Hydrochloride 2 milligram sublingual tablets are prescribed to treat chronic pain in multiple sites. 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 Buprenorphine Hydrochloride 2 milligram sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 25 milligram capsules prescribed for neuropathic 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. Your prescriber indicated that Pregabalin is prescribed to treat neuropathic pain. However, the Medicare approved compendia do not support the use of this drug to treat neuropathic pain when not related to certain other medical conditions. A physician reviewed your appeal and determined that the plan is not required to cover Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zolpidem Tartrate Extended Release 6.25 tablets prescribed to treat insomnia. 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. We also researched Medicare regulations and reviewed the enrollment data available. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plan requires that Doxepin 3 milligram or 6 milligram be tried and the prescriber must acknowledge that the benefit of the therapy with this prescribed medication outweighs the potential risks for this patient. The prescriber did not send the medical records supporting that Doxepin was tried previously and no statement was made on the acknowledgement of the benefit of the therapy outweighs the potential risk in this older adult. Therefore, the pre-authorization requirements were not satisfied.A physician reviewed your appeal and determined that the plan is not required to cover Zolpidem Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 milligram tablets prescribed for type 2 diabetes mellitus with hyperglycemia. 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. Jardiance 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 Hizentra 4 grams/ 20 milliliters for subcutaneous infusion prescribed as directed for common variable immunodeficiency and nonfamilial hypoglammaglobulinemia. 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 record shows the physician prescribed Hizentra for subcutaneous infusion to treat common variable immunodeficiency and nonfamilial hypoglammaglobulinemia. However, this drug may be eligible for coverage under Medicare Part B. This drug is eligible for coverage under Medicare Part B when it is administered in the home with a subcutaneous infusion pump.We determined that the plan is not required to cover Hizentra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eligard 7.5-milligram Kit to treat malignant neoplasm of prostate. 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: Favorable

At issue is Lenvima 4 milligram capsule therapy pack prescribed for endometrial cancer. 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. The medical records show you prescribed Lenvima 4 milligram capsule therapy pack to treat the enrollees endometrial cancer. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records support Lenvima being used as second line therapy with Keytruda for advanced/recurrent endometrial cancer, not microsatellite instability high/deficient mismatch repair, in an enrollee who cannot get surgery or radiation and has progressed on systemic therapy. The documentation provided does show the enrollee has satisfied the plan's coverage criteria.An oncologist reviewed your appeal and determined that the plan is required to cover Lenvima 4 milligram capsule therapy pack.