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

You requested Losartan 50 milligram tablets prescribed for unknown diagnosis. 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 you received Losartan as a self-administered drug while in the hospital. The National Drug Code submitted for payment to your plan for the Losartan was 00904-7048-61. We found that National Drug Code 00904-7048-61 is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover the Losartan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for Nepro/Carbsteady liquid prescribed for chronic kidney disease stage 3, moderate. 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 reviewed your appeal carefully. We reviewed all documentation available. Drugs/items prescribed that are available over-the-counter are excluded from coverage under Medicare Part D. Therefore, the requested item is excluded from coverage.We determined that the plan is not required to cover Nepro/Carbsteady liquid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gammaplex 10 milligram/100 milliliter prescribed to treat antibody mediated rejection of lung transplant. 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 records show your physician prescribed Gammaplex 10 milligram/100 milliliter to treat your antibody mediated rejection of lung transplant. 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 Gammaplex 10 milligram/100 milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Hydrocodone-Acetaminophen 10-325 milligrams to treat the enrollees condition. 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.Hydrocodone-Acetaminophen is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated if 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

You requested Repatha SureClick 140 milligrams/milliliter auto-injector pen for subcutaneous administration prescribed as directed. 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. At redetermination, a diagnosis of high risk cardiac illness was provided. At reconsideration, diagnoses of Birt-Hogg-Dube syndrome, hypertension, hyperlipidemia, and coronary artery disease were given. No medical records were provided by the prescriber to support these diagnoses. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Repatha SureClick.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rytary 48.75-195 milligram capsule prescribed for Parkinsons disease. 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. Rytary is a brand drug on Tier 4 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 coverage for Lidocaine 5% patches. The Part D plan forwarded the case to us for review. 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 medical records indicate that Lidocaine patches were prescribed to treat your right shoulder and rib pain after a fall. 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 requested drug is being prescribed for a non-medically accepted indication and 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 Lidocaine patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Nuedexta 20-10 milligram capsules to treat the enrollees condition.   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.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humalog 100 milliliter solution prescribed for diabetes. The Part D plan denied your requestWe 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 Humalog is being administered through an infusion pump in the home for treatment of diabetes. Medicare law specifically excludes coverage for any drug for which payment would be available under Part A or Part B of Medicare for that individual. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover the Humalog. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Doxepin Hydrochloride 50 milligram capsules prescribed for a sleep aid. 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 levelDoxepin Hydrochloride is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why the all alternative medications would not work for you. All generic drugs on lower tiers have not been tried. 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 Stivarga 40 milligram prescribed for your metastatic colorectal cancer. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The documentation supports the drug was prescribed for your condition. However, the enrollee does not 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

You requested Lidocaine Hydrochloride Gel 2% prescribed to treat moderate vulvar dysplasia. 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. We also researched Medicare regulations and Medicare approved compendia. The Medicare approved compendia does not support the use of the drug for your conditionA physician reviewed your appeal and determined that the plan is not required to cover Lidocaine Hydrochloride Gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipratropium-albuterol .5-3(2.5) milligram/3 milliliter solution prescribed for asthma. The Part D plan denied your request.We received a 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 Ipratropium-albuterol is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Ipratropium-albuterol. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vivelle-Dot 0.05 milligram patch to treat menopause. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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

You requested Xifaxan 550 milligram tablets prescribed three times daily for abdominal distension (gaseous) and gastro-esophageal reflux disease without esophagitis. 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. The submitted documentation indicates your doctor prescribed Xifaxan for abdominal distension and gastro-esophageal reflux disease. You have indicated the diagnoses should be small intestinal bacterial overgrowth, and/or irritable bowel syndrome. Your doctor submitted a statement indicating the diagnosis should be irritable bowel syndrome with diarrhea. The medical records submitted indicate the drug at issue was prescribed for small bowel bacterial overgrowth. There is no evidence to support a change in diagnosis to irritable bowel syndrome with diarrhea. 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 Albuterol 2.5 milligram/3 milliliter nebulizer solution 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.The record shows the medication is to be administered through durable medical equipment. This drug is eligible for coverage under Medicare Part B. We determined that the Part D plan is not required to cover Albuterol 2.5 milligram/3 milliliter. You may wish to submit you claim to Medicare Part B, durable medical equipment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ruconest 2100 Unit Vial prescribed to treat hereditary angioedema type 3. 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 plan requires prior authorization criteria be met for this drug to be covered. The physician indicated that the diagnosis being treated with this medication is hereditary angioedema type 3. This does not meet prior authorization requirements. A physician reviewed your appeal and determined that the plan is not required to cover Ruconest.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vumerity 231 milligram tablets to treat multiple sclerosis. 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 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 a tiering exception request for Vyvanse 20 milligram capsules prescribed for attention-deficit hyperactivity disorder, predominantly inattentive type. 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.This drug is being 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydroxyzine Hydrochloride 10 milligram tablet prescribed for insomnia and post-traumatic stress 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 records show you prescribed Hydroxyzine Hydrochloride 10 milligram tablet to treat the enrollees insomnia and post-traumatic stress 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 Hydroxyzine Hydrochloride 10 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz XR 11 milligram tablet to treat rheumatoid arthritis. 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.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We received a prescriber statement but did not receive the medical records requested.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 Sildenafil 20 milligram tablets prescribed for erectile dysfunction. The Part D plan denied your request.We received a case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is not required to cover Sildenafil. According to your plans Evidence of Coverage, drugs prescribed to treat sexual/erectile dysfunction are excluded from coverage under Medicare Part D. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Telmisartan Hydrochlorothiazide 80 milligram/25 milligram tablets prescribed for essential hypertension. 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 physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and failed, were contraindicated or would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Telmisartan Hydrochlorothiazide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Octreotide Acetate 50 micrograms/milliliter injection prescribed as directed for arteriovenous malformation (AVM) of small bowel, acquired with hemorrhage. 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. 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 drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and  determined that the plan is not required to cover the Octreotide Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Phentermine 30 milligram capsules prescribed once daily for abnormal weight gain. 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 physician prescribed Phentermine for abnormal weight gain. Drugs used to treat weight gain (promote weight loss) 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.We determined that the plan is not required to cover the Phentermine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine HCl 10 milligram tablets prescribed for chronic muscle spasms due to osteoarthritis. 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. The submitted documentation indicates your doctor prescribed Cyclobenzaprine HCl for chronic muscle spasms due to osteoarthritis. 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 Motegrity tablets to treat chronic constipation. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.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. Therefore, an exception to the plans coverage criteria is not supported.Our physician reviewer's opinion is that formulary exception criteria are not met.