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

At issue a request for coverage of Xtampza ER 27 milligram extended release tablets prescribed for pain related to head and neck cancer. 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. Xtampza ER is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all 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. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Kineret 100 milligrams per 0.67 milliliter syringe prescribed to treat autoinflammatory and periodic fever syndromes. 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 Kineret 100 milligrams per 0.67 milliliter syringe to treat autoinflammatory and periodic fever syndromes. 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 Kineret 100 milligrams per 0.67 milliliter syringe.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablet for small intestinal bacterial overgrowth. 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 this medication. We did not receive the documentation requested. The documentation shows your doctor prescribed Xifaxan to treat your small intestinal bacterial overgrowth. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage for Skyrizi 150 milligram per milliliter subcutaneous injection kit prescribed 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.The plan has prior authorization criteria that have to be met before coverage of this drug is allowed. The submitted documentation does not satisfy the plans coverage requirements. During this review, a request was submitted to the prescriber to address the plans coverage criteria for the medication and to provide supporting medical records. However, the prescriber did not respond to the request. Therefore, the prior authorization requirements have not been satisfied. 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 Hyoscyamine Sulfate ER 0.375-milligram tablet prescribed for irritable bowel syndrome and ulcerative colitis. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the physician prescribed Hyoscyamine Sulfate. Hyoscyamine Sulfate has not been approved by the Food and Drug Administration. Therefore, the requested drug is excluded from coverage.We  determined that the plan is not required to cover Hyoscyamine Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Caplyta 42 milligram capsules prescribed daily for post traumatic stress disorder and bipolar disorder. 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 documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed. The use of the requested drug to treat the provided diagnosis is an off-label use.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.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 Megestrol Acetate 40 milligram tablets prescribed for fallopian tube carcinoma and peritoneal carcinomatosis. The Part D plan denied the request stating that the provided diagnosis is 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.Your medical records show your doctor prescribed the requested Megestrol Acetate to be used in conjunction with Tamoxifen for fallopian tube carcinoma. 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.  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.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 Mexiletine Hydrochloride 150 milligram capsules prescribed to treat right foot 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 Mexiletine Hydrochloride 150 milligram capsules to treat right foot 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 Mexiletine Hydrochloride 150 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Xeljanz XR 11 milligram extended release 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 documentation indicates that Xeljanz XR has been prescribed for the treatment of refractory Takayasus arteritis, type V-P. 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 Pregabalin 50 milligram capsule prescribed twice daily for paresthesia and bilateral foot 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 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 Pregabalin to treat the enrollees paresthesia and bilateral foot pain. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed the appeal and determined that the plan is not required to cover Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets prescribed as directed  for other specified diseases of intestine, lower abdominal pain, unspecified, and irritable bowel syndrome without diarrhea. 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 Xifaxan to treat your other specified diseases of intestine, lower abdominal pain, unspecified, and irritable bowel syndrome without diarrhea. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rituxan 100 milligram/10 milliliter vial prescribed for Stiff-man syndrome. 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 your doctor prescribed Rituxan to treat your Stiff-man syndrome. 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 Rituxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cyclosporine 25 milligram capsules prescribed for immunosuppression following a kidney and pancreas 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 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.The Medicare Health Insurance Master Record (HIMR) system shows that the enrollee was enrolled in Medicare Part A and underwent a Medicare-covered double transplant on January 21, 2003, with a hospital discharge date of January 27, 2003. Since the patient was enrolled in Medicare Part A during the transplant, the Cyclosporine would be covered under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law. As such, our decision is that the Part D plan is not required to cover the requested drug. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Noxafil 40 milligram/ml suspension prescribed for candida glabrata and vertebral osteomyelitis. 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 Noxafil to treat candida glabrata and vertebral osteomyelitis. 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 Noxafil. 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 Tirosint 50 microgram capsule prescribed daily for hypothyroidism. 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 all the 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 Tirosint.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24-26 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. Entresto 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 Humira 40 milligram/0.4 milliliter pen injector prescribed for rheumatoid arthritis. 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 did not submit documents that support the enrollee had tried one conventional synthetic disease-modifying anti-rheumatic 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 Humira. 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: Favorable

At issue is Verzenio 200 milligram tablet prescribed twice daily for metastatic breast 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 records submitted at the reconsideration level.The medical records show the doctor prescribed Verzenio to treat the enrollees hormone receptor (HR) positive, human epidermal growth factor receptor 2 (HER2) negative metastatic breast cancer. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Per the Food and Drug Administration, Verzenio can be used as monotherapy for metastatic breast cancer, hormone receptor (HR) positive, human epidermal growth factor receptor 2 (HER2) negative after progression on endocrine therapy and chemotherapy in the metastatic setting. The enrollee has had both in the metastatic setting. Per the National Comprehensive Cancer Network, Verzenio is category 2A. Of note, it is not mentioned in the Food and Drug Administration label or the National Comprehensive Cancer Network compendia that the enrollee cannot have been on a similar class of medications before. According to prior authorization criteria, Verzenio can be given if the enrollee has been on other medications in the same class. This further supports that Verzenio can be given from a clinical standpoint with likely efficacy even though patient got Ibrance more than three years ago. Therefore, an exception to the plans coverage criteria is medically necessary.A physician reviewed the appeal and determined that the plan is required to cover Verzenio.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Simponi 50 microgram per 0.5 milliliter prefilled syringes prescribed for rheumatoid arthritis. 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. Simponi is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, 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. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Propafenone Hydrochloride 150 milligram tablets prescribed for atrial fibrillation. 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. Propafenone Hydrochloride is a generic drug on Tier 3 of the plans formulary. The prescriber has not sufficiently addressed all of the generic drugs of the same type on the lower tiers of the plans formulary to treat the noted condition. The prescriber has not explained why each lower tier alternative has been tried and failed or is contraindicated. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Remicade for solution 100 milligram prescribed for ulcerative colitis and rectal bleeding. 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 Remicade to treat your ulcerative colitis and rectal bleeding. 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 Remicade. 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 Omeprazole 20 milligram capsules, prescribed as one capsule twice a day, for gastroesophageal reflux disease without esophagitis. 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. Your medical records show your doctor prescribed Omeprazole to treat your gastroesophageal reflux disease without esophagitis. The plan approved the quantity limit of 20 milligram capsules for use as one capsule a day. However, your medical records do not support why an exception to the plans quantity limit is medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover the additional 20 milligrams daily of Omeprazole, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Tizanidine Hydrochloride 2 milligram tablets. The Part D plan denied the request because the drug was not included on the plans formulary and the documentation did not support a formulary 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.The documentation indicates that Tizanidine Hydrochloride has been prescribed for the treatment of chronic low back pain due to radiculopathy. 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 will not be addressed. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.