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

At issue is Rytary 61.25-245 milligram ER capsule prescribed two capsules four times daily for Parkinsons disease. 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. 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. A physician reviewed the appeal and determined that the plan is not required to cover Rytary ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zofran 4 milligram tablets prescribed as directed for cancer treated with oral chemotherapy. 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. Your doctor indicates that you cannot take generic Ondansetron, which has been approved at the 4-milligram dose. In this case, the drug is non-formulary and the non- formulary exception approvals include formulary drugs must be tried at maximum dosages. The medical records do not support why all other drugs, at their maximum recommended dosages, would not work for you.  A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  A physician reviewed your appeal and determined that the plan is not required to cover Zofran.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested test strips. 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.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

You requested a reimbursement for Acetaminophen-Codeine 300 milligram/30 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Acetaminophen-Codeine 300 milligram/60 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Advair Diskus 0.25 milligram/1 Actuation-0.05 milligram/1 Actuation. 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Albuterol Sulfate hfa 0.09 milligram/1 Actuation. 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Alprazolam 0.25 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Alprazolam 0.5 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Buspirone Hydrochloride 7.5 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Cyclobenzaprine Hydrochloride 10 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Diltiazem Hydrochloride ER 120 milligram capsules. 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Hydrocodone-Acetaminophen 5 milligram/325 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Hydroxyzine Hydrochloride 10 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Nitroglycerin 0.4 milligram sublingual 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Tramadol Hydrochloride 50 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Zolpidem Tartrate 10 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Zolpidem Tartrate 12.5 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 does not contain medical records to support a covered diagnosis. 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Cypionate 100 milligram per milliliter solution prescribed 200 milligrams intramuscular injection every four weeks for low testosterone. 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 Testosterone Cypionate to treat the enrollees low testosterone. At redetermination a diagnosis of hypogonadotropic hypogonadism was given. However, the medical records do not support this diagnosis. The Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Testosterone Cypionate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Oxycodone-Acetaminophen 10 milligram/325 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 does not contain 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 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

You requested Cresemba 180 milligram capsule prescribed for candida albicans osteomyelitis. 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 Cresemba to treat your candida albicans osteomyelitis. Cresemba has an orphan drug designation for invasive candidiasis in DrugDex, a Medicare approved compendium, and supports the use of this drug for your conditionA physician reviewed your appeal and determined that the plan is required to cover Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Privigen Solution 20 grams per 200 milliliters prescribed two days every month for lung transplant rejection. 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 Privigen Solution to treat the enrollees lung transplant rejection. 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 Privigen Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Actemra 162 milligram/0.9 milliliter subcutaneous solution prescribed for polymyalgia rheumatica. 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 Actemra for polymyalgia rheumatica. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As the drug was not 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 Dupixent 300 milligram/2 milliliter solution pen injection prescribed as directed for psoriasis, unspecified and bullous pemphigoid. 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 Dupixent to treat your psoriasis, unspecified and bullous pemphigoid. 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 Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prolia 60 milligram/milliliter injection prescribed for osteoporosis. 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.Your doctor submitted a supporting statement that indicates the prescriber is supplying the Prolia at issue. This is eligible for coverage under Part B. Your plan does not offer supplemental (additional) coverage for Prolia. 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 Promethazine Hydrochloride 25 milligram suppository prescribed for chronic migraine. 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 Promethazine Hydrochloride to treat your chronic migraine. 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 Promethazine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolastin-C 1000 milligram/20 milliliter injection prescribed for congenital alpha-1 antitrypsin deficiency. 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 Prolastin-C to treat your congenital alpha-1 antitrypsin deficiency. 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 Prolastin-C. The lab work does not confirm you meet the prior authorization criteria. 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 Oxycodone Hydrochloride extended-release 30 milligram tablets prescribed 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.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. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary 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.A physician reviewed your appeal and determined that the plan is not required to cover Oxycodone Hydrochloride extended-release 30 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zejula 100 milligram tablets prescribed for endometrial cancer. 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 Zejula for endometrial cancer. The Medicare approved compendia do not support the use of the drug at issue for your conditions. There are no Medicare approved journals to support the use of the drug for endometrial cancer. As the drug was not 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.