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

You requested ZTlido 1.8% patch to treat chronic pain 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.The documentation shows your doctor prescribed ZTlido 1.8% patch to treat your conditions. However, the use of the requested drug to treat the provided diagnoses is an off-label use. 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 ZTlido 1.8% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 5 milligram tablets prescribed for insomnia. 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 includes a supporting statement from your doctor. The statement does not support that you satisfy 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

At issue is Repatha Sureclick 140 milligrams/milliliter Auto injector prescribed for hypercholesterolemia. 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 provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are 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 coverage for Dextroamphetamine-Amphetamine 10 milligram tablets. The Part D plan denied the request because the prior authorization criteria were not met.  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 plans prior authorization requirement for coverage of Dextroamphetamine-Amphetamine is that the enrollee has a diagnosis of attention-deficit hyperactivity disorder; attention deficit disorder; or narcolepsy, which has been confirmed by a sleep study. The prescriber has noted at reconsideration that the enrollee has a diagnosis of attention deficit disorder. However, the submitted medical records do not indicate that the enrollee is being treated for attention deficit disorder. During this review, we requested a statement and supporting medical records from the prescriber to validate the diagnosis of attention deficit disorder. The prescriber did not respond to our request. Without medical records to validate the diagnosis it cannot be established that the Dextroamphetamine-Amphetamine is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent patch prescribed for dislocation of interphalangeal joint of the right great toe and pain in right foot. 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 prescriber initially provided the diagnosis of dislocation of interphalangeal joint of the right great toe and pain in right foot.  In the request for reconsideration, the prescriber changed the diagnosis to dorsalgia while under consultation for possible surgery with neurosurgeon. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Perphenazine-Amitriptyline 2-25 milligram tablet prescribed for major depressive disorder and other specified depressive episodes. 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 Perphenazine-Amitriptyline to treat major depressive disorder and other specified depressive episodes. 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 Perphenazine-Amitriptyline.
Appeal type: Prescription Drug
Decision: Favorable

You requested Rexulti 0.5 milligram tablets prescribed for major depressive 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.The record shows the enrollee has a diagnosis of major depressive disorder. The plan requires for coverage of Rexulti that the enrollee had prior therapy, intolerance, or contraindication to Aripipzaole and Quetiapine. The documentation includes clinical notes which satisfied the plan's coverage. A physician reviewed your appeal and determined that the plan is required to cover the Rexulti.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sirolimus 2 milligram tablet to treat liver transplant rejection.   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.A physician reviewed your appeal and determined that the plan is not required to cover Sirolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 7.5 milligram tablet prescribed twice daily for post-cardiac transplant heart dysfunction. 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 use of the requested drug to treat the provided diagnosis has an orphan drug designation. This means it has a medically accepted indication and may be a covered drug under a Part D plan. 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 your appeal and determined that the plan is not required to cover Corlanor. 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 Gralise 300 milligram tablets prescribed for major depressive disorder. 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 originally prescribed Gralise for major depressive disorder. Your doctor submitted a statement and medical records to indicate the drug was prescribed for medication-induced sweating. However, the Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that 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 Firvanq 25 milligram/milliliter solution prescribed for d-lactic acidosis and short gut syndrome. 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 originally prescribed Firvanq for d-lactic acidosis and short gut syndrome. Your doctor submitted a statement to indicate the drug was prescribed for recurrent clostridium dificle infections. However, the medical records do not support the drug was prescribed for recurrent clostridium dificile infections. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that 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 Ozempic 2 milligram/1.5 milliliter injection prescribed for type II 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.This drug is included on Tier 1 of the plans formulary. There are no cost-sharing tiers lower than Tier 1; 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

You requested Tramadol-Acetaminophen 37.5 milligram-325 milligram tablet prescribed for bilateral low back pain without sciatica, chronic back pain with radiculopathy and foot drop. 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 Tramadol-Acetaminophen 37.5 milligram-325 milligram tablet for bilateral low back pain without sciatica, chronic back pain with radiculopathy and foot drop. 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 Tramadol-Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eplerone 25 milligram tablet prescribed for 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 prescriber statement and medical records shows Eplerone was prescribed for heart failure. 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 prescriber did not address 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 Eplerone .
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zolpidem Tartrate 10 milligram tablets prescribed daily for spondylosis without myelopathy or radiculopathy, lumbosacral region, low back pain, and postlaminectomy syndrome. 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 Zolpidem Tartrate for spondylosis without myelopathy or radiculopathy, lumbosacral region, low back pain, and postlaminectomy syndrome. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that 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 Diclofenac Epolamine Patch 1.3% prescribed for unilateral primary osteoarthritis, unspecified knee and chronic kidney disease, stage 3b. 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. The documentation shows you were prescribed Diclofenac Epolamine Patch 1.3% to treat your osteoarthritis of the knee, unspecified. 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 Epolamine Patch 1.3%.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sodium Chloride tablet 1 gram tablet prescribed for hyponatremia. The Part D plan denied your request. We performed and 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 determined that the plan is not required to cover Sodium Chloride because it a nonprescription drug. Nonprescription or over-the-counter drugs are excluded from coverage. 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

You requested Megestrol Acetate 625 milligrams/milliliter oral suspension prescribed to treat anorexia. 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 Megestrol Acetate to treat your anorexia. 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 Megesterol Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cevimeline Hydrochloride 30 milligram capsules prescribed daily for xerostomia associated with radiation treatment. 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 Cevimeline Hydrochloride for xerostomia associated with radiation treatment. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that 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 Tymlos 80 microgram pen injector prescribed daily for osteoporosis with current pathological fracture in a male patient. 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 Tymlos to treat the enrollees osteoporosis with pathological fracture in a male patient. 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 Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dupixent 300 milligram/2 milliliter syringe prescribed every two weeks to treat atopic 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. This specialty drug was approved as a recurring 30-day supply, and up to a maximum of a recurring 90-day supply. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover a recurring supply over 90 days. A physician reviewed your appeal and determined that the plan is not required to cover a recurring supply over 90 days of Dupixent 300 milligram/2 milliliter syringe.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Corlanor 5 milligram tablets prescribed twice daily for chronic 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 indicates your doctor prescribed Corlanor for chronic heart failure. The documentation does not satisfy the plans coverage criteria in terms of ejection fraction. 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 Botox 100 unit vial prescribed for overactive bladder. 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.  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 you. A physician reviewed your appeal and determined that the plan is not required to cover Botox.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tremfya 100 milligrams/milliliter auto-injector prescribed for plaque psoriasis. 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 received a statement from your doctor that Tremfya was prescribed to treat plaque psoriasis. However, 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 Tremfya.
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 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 Coreg 6.25 milligram tablets prescribed twice daily for essential primary hypertension. 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 also researched Medicare systems and reviewed the enrollment data available. 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 Coreg.