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

At issue is Zolpidem Tartrate 10 milligram tablet prescribed for attention deficit hyperactivity disorder, predominantly inattentive type and major depressive disorder, recurrent, mild. 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 documents support that Zolpidem Tartrate 10 milligram tablet is prescribed for attention deficit hyperactivity disorder, predominantly inattentive type and major depressive disorder, recurrent, mild. 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 Zolpidem Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mobic 15 milligram tablets prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.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.This drug 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% gel prescribed for testicular hypofunction. 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 requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the plans formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.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 the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Testosterone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gamunex-C 40 milligram/400-milliliter solution prescribed every 30 days for autistic 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 Gamunex-C to treat the enrollees autistic disorder. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Gamunex-C.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tibsovo 250 milligram tablets prescribed as directed for myelodysplastic syndrome. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber initially provided the diagnosis of myelodysplastic syndrome.  In the request for reconsideration, the prescriber changed the diagnosis to acute myeloid leukemia.  We asked your prescriber to send us information regarding your change in 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.The documentation submitted shows your doctor prescribed Tibsovo to treat your myelodysplastic syndrome. However, the Medicare approved compendia do not support the use of this drug for your condition. The records do not support a diagnosis of acute myeloid leukemia. A physician reviewed your appeal and determined that the plan is not required to cover Tibsovo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Patch 5% prescribed for osteoarthritis of the knee. 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. The information received indicates that Lidocaine Patch 5% is prescribed to treat osteoarthritis of the knee. 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 Lidocaine Patch 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cefdinir 300 milligram capsule prescribed for a urinary tract infection. 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 indicates that Cefdinir 300 milligram capsule is prescribed to treat a urinary tract infection. 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 Cefdinir.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for Temozolomide 180 milligram capsule prescribed for neuroendocrine cancer. The Part D plan denied the request because this drug is not covered under Medicare Part D. We performed and 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 plan is not required to cover Temozolomide because it is not covered under Medicare Part D. This drug is being used to treat cancer and should be covered under Medicare Part A and/or Part B. 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 a prior authorization request for Icatibant 30 milligram/3 milliliter solution prescribed for hereditary angioedema. The Part D plan denied coverage.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 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 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 Enbrace HR capsule prescribed for bipolar 1 disorder, genetic abnormality, and methylenetetrahydrofolate reductase abnormality. 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 documentation shows Enbrace HR capsule was prescribed for bipolar 1 disorder, genetic abnormality, and methylenetetrahydrofolate reductase abnormality. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Enbrace HR.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Clenpiq 10 milligram/3.5 gram/12 gram/160 mililiter solution 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.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the Clenpiq solution was purchased. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined this drug was paid correctly and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 100 milligram capsule prescribed three times daily. The Part D plan denied the request for a tiering exception.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. Pregabalin is a generic drug on Tier 3 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Austedo 12 milligram tablet prescribed for dystonia. 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 indicates that Austedo 12 milligram tablet is prescribed to treat tardive dystonia. 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 Austedo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 5 milligram capsule. 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. The information received indicates that Dronabinol 5 milligram capsule is not being used as an intravenous medication and it is not being used as an anti-emetic for nausea. It is also stated that the drug is being used to enhance appetite as the enrollee has pancreatic cancer Stage 3, on chemotherapy, and it makes the enrollee nauseous and unable to eat. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 1% gel prescribed for plantar fascial fibromatosis and benign neoplasm of peripheral nerves and autonomic nervous system. 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 prescriber originally ordered Diclofenac Sodium for plantar fascial fibromatosis and benign neoplasm of peripheral nerves and autonomic nervous system. 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 Diclofenac Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 5 milligram tablet prescribed for insomnia. 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. The plan's prior authorization requirements have not been met. A physician reviewed your appeal and determined that the plan is not required to cover Zolpidem Tartrate. 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 Eliquis 5 mg tablets 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. Eliquis 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

You requested Octreotide Acetate 100 microgram/milliliter vial prescribed every 17 days for gastric antral vascular ectasia. 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 Octreotide Acetate to treat the enrollees gastric antral vascular ectasia. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Octreotide Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram/milliliter 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. Repatha Sureclick is a biological product drug on Tier 3 of the plans formulary. There are no biological product 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 Enbrel Sureclick Injection 50 milligram/milliliter prescribed weekly. The Part D plan denied the request for a tiering exception.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. This drug is included on Tier 4 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Myrbetriq 50 milligram 24-hour tablet to treat the enrollees condition. 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.Myrbetriq 50 milligram tablet is a brand drug on Tier 3 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

At issue is Wegovy 0.25 milligram/0.5-milliliter solution prescribed weekly. The Part D plan denied your request because drugs prescribed to treat weight loss do not meet the definition of Part D drugs.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 plan is not required to cover Wegovy because it was prescribed to treat weight loss. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, he/she must pay for them. 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 Linzess 290 microgram capsule prescribed for irritable bowel syndrome with constipation. 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 290 microgram 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 Gattex 5 milligram kit prescribed for short bowel syndrome in an enrollee not dependent on parenteral nutrition. 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 prescriber originally ordered Gattex for short bowel syndrome in an enrollee not dependent on parenteral nutrition. 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 Gattex.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Metaxalone 800 milligram tablet prescribed for cervicalgia and muscle spasms. 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 medical records show the physician prescribed Metaxalone to treat the enrollees cervicalgia and muscle spasms. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of the requested drug for your condition. Metaxalone is indicated for the relief of discomfort associated with acute, painful musculoskeletal conditions The records show that the enrollee cannot take other drugs on the plans formulary for his condition. Specifically, Baclofen and Carisoprodol were tried and caused drowsiness and incoherence.A physician reviewed the appeal and determined that an exception can be granted to cover the drug that is not on the plans formulary. Therefore, the plan is required to cover Metaxalone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Colchicine 0.6% capsule prescribed for chondrocalcinosis and pseudogout. The Part D plan denied the request because the requested drug is not included on the plans formulary. 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 Colchicine was prescribed for chondrocalcinosis and pseudogout. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. Since the drug is not eligible for coverage under Part D, the plans formulary exception requirements are not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.A physician reviewed your appeal and determined that the plan is not required to cover Colchicine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 100 milligram tablet prescribed for somnolence, 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 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. The prescribers records indicate that the enrollee has memory deficits and the enrollee claims she has chemo brain and forgetful after having chemotherapy treatments. 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 Modafinil.