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

You requested Zonisamide 100 milligram capsules prescribed as directed for dystonia of the left arm with dystonic hand tremor. 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 Zonisamide to treat your dystonia of the left arm with dystonic hand tremor. 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 Zonisamide.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Cyclophosphamide 50 milligram capsules. 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 submitted medical records indicate that Cyclophosphamide has been prescribed for immunosuppressive therapy due to the presence of anti-glomerular basement membrane disease and antineutrophil cytoplasmic antibody (ANCA) vasculitis. The Medicare approved compendia contain citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for a medically accepted indication and is eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mavyret 100-40 milligram oral tablet prescribed daily for chronic hepatitis C. 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 Mavyret.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temozolomide 250 milligram capsule prescribed for treatment of pancreatic cancer. 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. Medicare rules state that drugs taken orally during cancer chemotherapy provided they have the same active ingredients and are used for the same indications as chemotherapy drugs that would be covered if they were not self-administered, are covered under Part B. Part D excludes any drug for which payment would be available under Medicare Part A or Part B for that individual. The record shows the drug was prescribed to be used as an orally administered chemotherapy agent. We determined the Part D plan is not required to cover the Temozolomide. 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 Vraylar 1.5 milligram capsules prescribed as directed for major depressive disorder, recurrent, mild and unspecified mental disorder due to known physiological condition. 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 Vraylar to treat your major depressive disorder, recurrent, mild and unspecified mental disorder due to known physiological condition. 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 Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Zolpidem Tartrate 5 milligram tablets prescribed for insomnia. 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 Part D plan has prior authorization requirements that must be met before coverage of this medication will be approved. 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 a request for coverage of Vyvanse 20 milligram capsules. 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 Vyvanse has been prescribed for the management of multiple sclerosis related fatigue. 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zarxio Solution 300 microgram/0.5 milliliter injector prescribed for leukopenia in an enrollee status post a heart transplant. 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 medical records submitted support that Zarxio was prescribed for leukopenia, unspecified type. The etiology of the leukopenia is not discussed in the provided records. 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 Zarxio.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 4.5 milligram capsules prescribed for the enrollees condition. 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 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. 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 Nitroglycerin extended release 6.5-milligram capsule 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. The record shows the pharmacy submitted a claim for Nitroglycerin with a National Drug Code of a drug that has not been approved by the Food and Drug Administration. Drugs that have not been approved by the Food and Drug Administration do not meet the definition of a Part D Drug and are not eligible for coverage under the Part D Prescription Drug Benefit.We reviewed your appeal and determined that the plan is not required to cover the Nitroglycerin extended release 6.5-milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omnipod Dash prescribed for the enrollees condition. 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.Omnipod Dash 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 Diltiazem 24 hour Extended Release 240 milligram capsule. 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. Diltiazem 24 hour Extended Release capsule is a generic drug on Tier 2 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sumatriptan Succinate 25 milligram tablet prescribed 16 tabs every 30 days for headaches, unspecified. 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 Sumatriptan Succinate to treat your headaches, unspecified. Medical records from date of service 6/8/2021 were provided which support a diagnosis of 'New onset of headaches.' However, the Medicare approved compendia do not support the use of this drug for your condition. The medical records do not support you have a covered diagnosis.A physician reviewed your appeal and determined that the plan is not required to cover Sumatriptan Succinate. Your request for a quantity limit exception was not reviewed. We cannot consider a quantity limit exception for a drug for which the Medicare Part D plan is unable to provide coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lamotrigine Extended Release 200 milligram tablet. 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. Lamotrigine Extended Release 200 milligram tablet is a generic drug on Tier 4 of the plans formulary. The medical records do not support that all drugs available on lower tiers 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 Lidocaine Ointment 5% prescribed for post herpetic neuralgia. 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. Your prescriber indicates they prescribed Lidocaine Ointment 5% to treat post herpetic neuralgia. However, Medicare approved compendia do not support the use of this drug for your condition.  A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine Ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amantadine Hydrochloride 100 milligram capsules prescribed daily for the enrollees condition. 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.Amantadine Hydrochloride is a generic drug on Tier 4 of the plans formulary. The documentation on hand does not address why all alternative lower-tier medication on the plans formulary would not work for you. All 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 Cyclobenzaprine Hydrochloride 10 milligram tablet prescribed for fibromyalgia. 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 plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Your prescriber submitted documents supporting the medication is prescribed for fibromyalgia and the benefits of the medication outweighs the risks for the enrollee. However, there is no documentation supporting the enrollee had tried and failed duloxetine or had an intolerance, contraindication, or hypersensitivity to the drug. The documentation provided does not support you have satisfied the plan's prior authorization requirements. A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine Hydrochloride. 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 Gattex 5 milligram kit prescribed for chronic diarrhea and short bowel 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 Gattex for chronic diarrhea and short bowel syndrome. 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 Dextroamphetamine-Amphetamine 10 milligram tablets prescribed for multiple sclerosis related fatigue. 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 include medical records to support a covered diagnosis. The original diagnosis submitted for review is not supported by the Medicare approved compendia as a medically accepted indication. 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

At issue is a request for coverage of Welchol 625 milligram tablets. 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 prescriber has noted that the Welchol has been prescribed for the treatment of pancreatic steatorrhea. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for 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. Since the drug is not eligible for coverage under Medicare Part D, a formulary exception is not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cayston 75 milligram inhalation solution prescribed for bronchiectasis with recurrent Pseudomonas infections. 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. Your prescriber indicates they prescribed Cayston 75 milligram inhalation solution for bronchiectasis with recurrent Pseudomonas infections. 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 Cayston.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Deferasirox 360 milligram tablet prescribed twice daily for iron overload secondary to blood transfusions. 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 Deferasirox to treat your iron overload secondary to blood transfusions. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided supports you have satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan may cover Deferasirox. Your platelet counts exceed the minimum criteria of 50 x 10^9/L. Therefore, the prior authorization requirements have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Samsca 15 milligram tablets prescribed for hypervolemic hyponatremia associated with chronic syndrome of inappropriate antidiuretic hormone (SIADH). 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 Part D plan has prior authorization requirements that must be met before coverage of this medication will be approved. 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

You requested Baclofen 5 milligram tablet prescribed for unknown diagnosis.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.According to the Food and Drug Administration, Baclofen 5 milligram tablet has a National Drug Code that is not eligible under Part D. Therefore, we determined that the plan is not required to cover or reimburse you for the Baclofen 5 milligram tablet. 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 Xifaxan 550 milligram tablet 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 purchased Xifaxan from a preferred pharmacy for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined your copay for Xifaxan was calculated correctly and no further reimbursement is required by the plan.