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

You requested Cyclobenzaprine 10 milligram tablets prescribed as directed for long-term treatment of muscle spasms/pain. 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 Cyclobenzaprine to treat your long-term treatment of muscle spasms/pain. 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 Cyclobenzaprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omeprazole 20 milligram capsule delayed release compounded into liquid 2 milligrams per milliliter prescribed for treatment of gastroesphageal reflux 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 reviewed 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 submitted documentation that shows the compounded drug contains ingredients that do not meet the definition of a Part D drug when part of a compound. Therefore, the requested compounded drug is excluded for coverage under Part D. 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

At issue is Armodafinil  250-microgram tablets prescribed as directed for obstructive sleep apnea. 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 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 Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xtampza 9-milligram Extended Release Capsule 12-Hour Abuse Deterrent to treat chronic right shoulder pain and osteoarthritis left shoulder. The Part D plan denied the request. The requested drug is not on the plans formulary. 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.We asked your prescriber to send us a prescriber statement, answers to non-formulary coverage criteria, and medical records. 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 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 formulary exception request for Paliperidone 6-milligram extended release tablets prescribed for schizoaffective disorder. 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 requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed. The prescriber submitted medical records and a statement, which we included in this review.The submitted documentation did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Paliperidone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cimzia 200 milligrams per 1 milliliter syringe, 400 milligrams weeks zero, two, and four, then every two weeks for plaque psoriasis. 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. We asked the prescriber to send us information regarding the enrollees diagnosis. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. We received the documentation and included it in our review.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 Cimzia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xolido 2% cream to treat the enrollees condition.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.Xolido 2% cream is available over the counter. According to Medicare, drugs prescribed that are available over the counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage. Therefore, we determined that the plan is not required to cover and/or reimburse the enrollee for Xolido 2% cream. 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 Benztropine Mesylate 1 milligram tablet to treat schizophrenia. The Part D plan denied the request because prior authorization requirements were not met.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of Benztropine Mesylate to treat schizophrenia is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D. Since Benzatropine Mesylate is not eligible for coverage under Part D, the plans prior authorization requirements are not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover Benztropine Mesylate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Buprenorphine 7.5-microgram/hour patch prescribed for severe pain in an enrollee requiring a long-term daily around-the-clock opioid analgesic. 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 submitted documentation did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Buprenorphine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 1.5-milligram capsules prescribed for major depressive disorder. 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 submitted shows the prescriber ordered Vraylar to treat the enrollees condition of Major depressive disorder. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed the appeal and determined that the plan is not required to cover Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nystatin 100,000 units per gram powder prescribed to treat the diagnoses of actinic keratosis and dermatitis, unspecified. The Part D plan denied the appeal 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 Nystatin 100,000 units per gram powder to treat actinic keratosis and dermatitis, unspecified. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Nystatin 100,000 units per gram powder.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5-percent ointment prescribed for low back pain due to obesity. 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 requested additional documentation from the prescriber. Specifically, we requested medical records and a prescriber statement. We received additional information and included it in the review.The submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 Nulojix 250-milligram intravenous injection prescribed following a kidney transplant. 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 also researched Medicare systems and reviewed the enrollment data available. Based on the information provided, the biologic is eligible for Part B coverage. The plan does not offer supplemental (additional) coverage for this biologic. If the enrollee purchased biologics that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the biologic. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Freestyle Libre Sensor prescribed for type II diabetes. 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 item at issue is not directly related to the administration of insulin. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this item. If the enrollee purchased items that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the item. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 145 microgram capsule prescribed as directed. 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. Linzess is a brand drug on Tier 3 of the plans formulary. There are no brand 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 Humulin R U-500, 500 units per milliliter prescribed 60 units twice daily for type 2 diabetes mellitus with hyperglycemia. 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. We asked the prescriber to send us information regarding the enrollees diagnosis. We also asked for medical records or other documentation to show why this amount of the medication was required. We received the documentation and included it in our review.The medical records show the prescriber ordered a 90-day supply of Humulin R U-500 to treat the enrollees type 2 diabetes mellitus with hyperglycemia. However, the medical records do not support why an exception to the plans quantity limit is medically necessary. The plan limits the amount of Humulin R U-500 provided to a 30-day supply.A physician reviewed the appeal and determined that the plan is not required to cover the Humulin R U-500 as an exception to the plans coverage criteria is not supported.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Repatha 140 milligram per milliliter prefilled subcutaneous injection syringe prescribed for hyperlipidemia and type II diabetes mellitus. 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. Repatha is not included in the plans formulary (list of covered drugs). The prescriber and enrollee have noted that the enrollee is statin intolerant. However, the prescriber has not provided patient specific clinical rationale as to why the alternative drug included in the plans formulary, Praluent, would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. It should be noted that Praluent is not a statin and is the same class of drug as Repatha, a proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitor. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine Hydrochloride 12.5-milligram tablets. 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 requested additional information from the prescriber. Specifically, we requested medical records to support a prescribed diagnosis. The submitted documentation does not include medical records or evidence of a prescribed diagnosis. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.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 Bromfenac Sodium to treat cystoid macular degeneration. 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 use of Bromfenac Sodium to treat cystoid macular degeneration is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover Bromfenac Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Modafinil 100 milligram tablets. The Part D plan denied the request for coverage because the documentation did not support the drug was being use for a medically accepted indication. 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 Modafinil has been prescribed for the treatment of fatigue related to multiple sclerosis. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of the noted condition.At reconsideration, it has been noted that the requested drug is being used to treat fatigue due to depression. However, the previously submitted medical records do not indicate that Modafinil is being prescribed for fatigue related to depression and no new medical records have been submitted at reconsideration to confirm this additional diagnosis. Therefore, there is insufficient documentation to determine if the requested drug is being prescribed for a medically accepted indication. As such, the requested drug 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 Armour Thyroid to treat hypothyroidism. 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 record shows the physician prescribed Armour Thyroid. However, Armour Thyroid has not been approved by the United States Food and Drug Administration. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage. 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

Covered in Part B-UNFAVORABLEAt issue is Inflectra 100 milligram vial prescribed for psoriatic arthritis. 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. We determined that the drug is not eligible for Part D coverage. However, this drug may be eligible for coverage under Medicare Part B. A physician reviewed the appeal and determined that the plan is not required to cover Inflectra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Repatha Sureclick 140-milligram/milliliter auto-injector prescribed for atherosclerotic heart disease of native coronary artery without angina pectoris, and hyperlipidemia, 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 submitted documentation did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lumakras 120-milligram tablet to treat stage 4 neuroendocrine cancer of lung with KRAS G12C mutation. 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.We asked your prescriber to send us a prescriber statement, clarification of a medically accepted indication, answers to prior authorization coverage criteria and off formulary coverage criteria, and medical records. We received only a prescriber statement, which is included in this decision.The prescriber included a diagnosis of stage IV non-small cell lung cancer (large cell neuroendocrine) with KRAS G12C mutation. However, there are no documents submitted to support that this type of patient was included in the approval trials of Lumakras. Currently, the Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 Mesalamine 1000-milligram suppositories prescribed for the treatment of ulcerative proctitis. 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.Mesalamine suppositories are not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient patient specific clinical rationale as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.