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

At issue is a prior authorization request for Xifaxan 550 milligram tablets prescribed for hepatic encephalopathy. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies 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. Of note, you requested a quantity of Xifaxan greater than the plans allowance. As the drug has not been approved, a quantity limit exception cannot be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec ODT 75 milligram oral tablet prescribed daily for migraines. 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 Nurtec.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Prolia 60 milligram per milliliter subcutaneous injection syringe prescribed for postmenopausal osteopenia of the lumbar spine. 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. The Medicare approved compendium, DrugDex, includes a citation for the off-label use of Prolia in the treatment of postmenopausal women with low bone mass density (osteopenia) of the lumbar spine. The citation notes that in a randomized study of postmenopausal women with low bone mineral density of the lumbar spine, as evidenced by a T-score of -1 to -2.5, Prolia improved bone mineral density from baseline compared with placebo.During this review, a request was sent to the prescriber to submit the enrollees medical records and Dual-Energy X-ray Absorptiometry (DEXA) scan results to validate the diagnosis of postmenopausal osteopenia of the lumbar spine. The prescriber submitted the requested information. However, the enrollees latest DEXA scan results obtained on December 21, 2020, do not support a diagnosis of osteopenia of the lumbar spine, as the enrollees T-score of the lower spine is noted to be -0.3, which is classified in the normal range according to the World Health Organization criteria. 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 Botox 200 unit reconstituted solution prescribed for chronic migraine without aura, intractable, without status migrainosus. 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 Botox 200 unit reconstituted solution to treat chronic migraine without aura, intractable, without status migrainosus. 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 prescriber does not state why all 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 Botox 200 unit reconstituted solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Suboxone 8 milligram - 2 milligram sublingual film prescribed for chronic severe pain. 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 Suboxone sublingual film to treat chronic severe 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 Suboxone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for low back pain and spondylosis without myelopathy or radiculopathy, thoracic region. 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 Lidocaine 5% patch prescribed for low back pain and spondylosis without myelopathy or radiculopathy, thoracic region. 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Motegrity 2 milligram tablet for chronic idiopathic constipation. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need this medication. We received the documentation and included it in our review.Your medical records show your doctor prescribed Motegrity to treat your chronic idiopathic constipation. 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 Motegrity. 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 Adcirca 20 milligram tablets prescribed to treat pulmonary hypertension. 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 Adcirca 20 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil Citrate 20 milligram tablets prescribed twice daily for unspecified pulmonary 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.The submitted documentation indicates your doctor prescribed Sildenafil Citrate for unspecified pulmonary hypertension. 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

At issue is Vraylar 3 milligram tablet prescribed once a day for unspecified bipolar 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 shows the doctor prescribed Vraylar to treat the enrollees unspecified bipolar disorder. However, the Medicare approved compendia do not support the use of this drug for this unspecified 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 Travatan Z 0.004% eye-drop solution prescribed for open angle glaucoma. 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 documentation does not support the formulary alternative Travopost contains an ingredient that you are allergic to. Therefore, we are unable to approve your exception request.A physician reviewed your appeal and determined that the plan is not required to cover Travatan Z.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pennsaid Solution 2% prescribed for osteoarthritis of bilateral knees, right hip, ankles and wrist. 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 prescriber clarified the diagnosis in the request for reconsideration dated 6/28/2021. Relevant medical records were requested but not provided. Pennsaid Solution 2% is not on the plan's formulary.  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 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. A physician reviewed your appeal and determined that the plan is not required to cover Pennsaid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia subcutaneous solution prefilled syringe 60 milligram/milliliter prescribed for osteopenia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.Your medical records show your doctor prescribed Prolia to treat your osteopenia. 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 Prolia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 10 milligram capsule prescribed for persistent and debilitating pain. 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 Dronabinol 10 milligram capsules to treat persistent and debilitating 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Pregabalin 150 milligram capsules. The Part D plan denied the request because the plans prior authorization requirements were not met due to the provided diagnosis. 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 Pregabalin has been prescribed for the management of pain due to scoliosis-related lumbar and thoracic radiculopathy and spondylosis. 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 a request for coverage of Xalkori 250 milligram capsules prescribed for the treatment of metastatic stage 4, ER +, CDH1-mutated, invasive lobular cancer of the left breast. The Part D plan denied the request stating that the drug was being used for a non-medically accepted indication. 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 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 the use of the requested drug for the treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a prior authorization for Doxepin Hydrochloride 100 milligram capsules prescribed for anxiety. 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. 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 cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zoledronic Acid 5 milligram/100 milliliter prescribed for osteoporosis. 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 Zoledronic Acid is being prescribed to the enrollee for treatment of osteoporosis. Medicare law specifically excludes coverage for any drug for which payment would be available under Medicare Parts A or B for that individual. Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner). Zoledronic Acid is a type of drug that must be administered under direct observation of a health care provider and monitored for at least two hours after administration. The Food and Drug Administration has mandated a Risk Evaluation and Mitigation Strategy for Zoledronic Acid. This strategy requires that Zoledronic Acid be only dispensed and administered to patients in a medically supervised healthcare setting that monitors the enrollee. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Zoledronic Acid. 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: Favorable

At issue is Omnipod DASH pods prescribed every 72 hours for type 2 diabetes mellitus with hyperglycemia. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The records show the doctor prescribed Omnipod DASH pods to treat the enrollees type 2 diabetes mellitus with hyperglycemia. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollee was checking multiple blood glucose readings daily with the continuous sensor and received insulin around the clock with significant fluctuations in blood glucose including hypoglycemia. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Omnipod DASH pods.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aprepitant 4 milligran capsule prescribed daily for nausea and vomiting due to gastroparesis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we reviewed the appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.You state your doctor prescribed Aprepitant to treat your nausea and vomiting due to gastroparesis. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed this appeal and determined that the plan is not required to cover Aprepitant.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 8 milligran orally disintegrating tablet prescribed every eight hours as needed for nausea and vomiting due to gastroparesis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we reviewed the appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.You state your doctor prescribed Ondansetron to treat your nausea and vomiting due to gastroparesis. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed this appeal and determined that the plan is not required to cover Ondansetron.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Forteo 620 microgram per 2.48 milliliter subcutaneous injection pen prescribed for age-related osteoporosis with current pathological fracture. 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 Viibryd 20 milligram tablets prescribed as directed for generalized anxiety 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 documentation shows your doctor prescribed Viibryd to treat your generalized anxiety disorder. 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 Viibryd.
Appeal type: Prescription Drug
Decision: Unfavorable

At initial determination and redetermination, Osphena 60 milligram tablet was prescribed daily for mixed incontinence. 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. At reconsideration, the doctor prescribed Osphena to treat vaginal atrophy, without mention of vaginal dryness. 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 Osphena.