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

You requested Privigen solution 10 gram/100 milliliter prescribed for nonfamilial hypogammaglobulinemia. 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 received the documentation and included it in our review.The documentation shows your doctor prescribed Privigen to treat your nonfamilial hypogammaglobulinemia. 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 Privigen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Divalproex Sodium DR for maintenance treatment of bipolar II disorder. 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.Divalproex Sodium DR is a generic drug on Tier 3 of the plans formulary. The prescriber has not provided patient specific clinical rationale, with supporting medical documentation, to indicate that 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 Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed for post laminectomy syndrome and spondylosis of the lumbar region. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Your prescriber indicates that Cyclobenzaprine Hydrochloride 10 milligram tablets are prescribed for muscle spasms in the lower back and legs not associated with a painful acute musculoskeletal condition.  Medicare approved compendia does not support this drug for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 4-milligram tablet to treat hyperlipidemia. The Part D plan denied the request. 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 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: Favorable

At issue is Calcitriol 0.25 microgram capsule, a quantity of 15 capsules per 30 days. At initial coverage determination the diagnosis of end stage renal disease was given. At redetermination level the diagnoses of vitamin D deficiency and hyperparathyroidism were provided. The Part D plan denied the request stating the medication is end stage renal disease related and not covered under Medicare Part D.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 level the diagnoses of chronic kidney disease, renal osteodystrophy, and vitamin D deficiency were given. It is stated that the patient has not been on dialysis since April of this year. We asked your prescriber to send us information regarding your condition(s). We also asked for medical records and other documentation to show why you need this medication. We received the documentation and included it in our review.We determined that the drug is not eligible for Part B coverage. The medical records support that the enrollee is no longer on dialysis. Therefore, the drug can be considered for payment under the Part D benefit.Your medical records support chronic kidney disease with secondary hyperparathyroidism. The following citation was referenced in DrugDex, a Medicare approved compendia, and supports the use of this drug for your condition: Calcitriol is indicated in predialysis patients for the management of secondary hyperparathyroidism and resultant metabolic bone disease in patients with moderate to severe chronic renal failure who are not yet receiving dialysis.A physician reviewed your appeal and determined that the plan is required to cover Calcitriol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Exjade 500 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 Exjade has been prescribed for the management of sideroblastic anemia and elevated ferritin levels. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the Exjade.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Octreotide Acetate 20 microgram per milliliter solution prescribed for anemia related gastrointestinal bleed. 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 Octreotide Acetate to treat your anemia with associated gastrointestinal bleed. 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 Octreotide Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Xtampza ER 9 milligram capsules 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. A request for additional information was sent to your physician. Your physician submitted a supporting statement and medical records. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Xtampza ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Percocet 10-325-milligram tablet to treat pain.  The Part D plan denied the request. 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 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 is Buprenorphine 20 microgram/hour patch prescribed 1 patch every 7 days for severe kyphoscoliosis and cervical dystonia. We received the case to perform an independent and de novo review. 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. We did not receive the documentation requested.Your medical records show your doctor prescribed Buprenorphine to treat your severe kyphoscoliosis and cervical dystonia. 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 Buprenorphine. 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 Trulicity 0.75 milligram per 0.5 milliliter pen. 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. Trulicity is a biological product drug on Tier 3 of the plans formulary. There are no biological product 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 Dofetilde 250 microgram oral capsule prescribed twice 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.Dofetilde is a generic drug on Tier 4 of the plans formulary. The medical records do not support that all drugs available in the plans formulary to treat your condition have been tried or deemed contraindicated. 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 Nexlizet 180-10 milligram tablets prescribed to treat chronic cerebral ischemia.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 Nexlizet 180-10 milligram tablets to treat chronic cerebral ischemia. 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 Nexlizet 180-10 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsule prescribed for circadian rhythm sleep 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 records submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need this medication. We did not receive the documentation requested.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 Hetlioz. 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 a prior authorization request for Stelara 45 milligram/0.5 milliliter subcutaneous injection prescribed for plaque psoriasis with psoriatic arthritis. 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 includes a physician supporting statement. Medical records were provided. 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: Unfavorable

At issue is a tiering exception request for Eliquis 5-milligram tablet to treat deep vein thrombosis, acute embolism and thrombosis of femoral vein, bilateral. 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.Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. 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

You requested Arikayce 590 milligram per 8.4 milliliter suspension. 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 Arikayce to treat your lung infection caused by mycobacterium chelonae. However, the Medicare approved compendia do not support the use of this drug for your 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 Arikayce.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Inbrija 42-milligram inhalation capsule prescribed two capsules daily for Parkinsons 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. 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 Kynmobi (on the plans formulary) would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Inbrija.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 10 milligram oral capsule 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 drug is not included on your plans formulary. 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

You requested coverage for Ambien CR 12.5 milligram extended release tablets prescribed for 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 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.During this review, a request was submitted to your prescribing practitioner to address the plans coverage criteria for the medication and to provide supporting medical records. However, the prescriber did not respond to the request. The prescriber has not 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 a request for coverage of Xifaxan 550 milligram tablets prescribed for irritable bowel syndrome with diarrhea. 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. During this review, a request was sent to the prescriber to address the plans prior authorization requirements for coverage of Xifaxan. The prescriber responded to the request and provided documentation. However, the plans coverage criteria were not validated by the provided medical records. Clear documentation in the medical record of trial and failure of required alternatives is not present. 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 Incruse Ellipta 62.5 microgram inhaler prescribed for chronic obstructive pulmonary 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. 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.We received a prescribers statement, which shows Incruse Ellipta was prescribed to treat your chronic obstructive pulmonary disease. 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 and prescribers statement 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 Incruse Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligram tablets to treat insomnia, unspecified. 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: Unfavorable

You requested Cyanocobalamin 1000 microgram injection prescribed daily for two weeks for decreased Vitamin B12 levels. We performed and independent and de novo review. We reviewed all documentation submitted. We determined that the plan is not required to cover Cyanocobalamin because it it is a prescription vitamin and mineral product. Vitamins are excluded from coverage. 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 Mycophenolate Mofetil 500 milligram tablets prescribed for hypersensitivity pneumonitis. 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.Your doctor originally prescribed Mycophenolate Mofetil for interstitial lung disease. No medical records were received to support a diagnosis. A request for information was sent to your physician. Medical records were received. The submitted documentation indicates your doctor prescribed Mycophenolate Mofetil for hypersensitivity pneumonitis. The Medicare approved compendia do not support the use of the drug at issue for your conditions. 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.