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

You requested Lidocaine 5 percent patch prescribed for other chronic pain. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration 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 record shows you were prescribed the Lidocaine patch for your other chronic pain. The Medicare approved compendia do not support the use of this drug, as prescribed, for your 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 Buprenorphine Hydrochloride 8 milligram sublingual tablets prescribe to treat 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. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia does 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 Buprenorphine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Novolog U 100 insulin. The Part D plan auto-forwarded the case. We received a request for reconsideration.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 submitted does not include medical records indicating what this drug was prescribed for. As such, we cannot reimburse you for the drug until it can be determined that it was medically necessary for your condition.A physician reviewed your appeal and determined that the plan is not required to reimburse you for Novolog.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Simvastatin 10 milligram tablets. The Part D plan auto-forwarded the case. We received a reconsideration 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 submitted does not include medical records indicating what this drug was prescribed for. As such, we cannot reimburse you for the drug until it can be determined that it was medically necessary for your condition.A physician reviewed your appeal and determined that the plan is not required to reimburse you for Simvastatin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Octagam 10 gram per 100 milliliter solution. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Octagam has been prescribed for autoimmune peripheral neuropathy and Melkersson-Rosenthal syndrome. However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Octagam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 milligram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Jardiance 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 Victoza 0.6 milligram per 0.1 milliliter pen prescribed for diabetes mellitus. The Part D plan did not make a decision.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.Step therapy was previously approved by the plan and is not addressed here. Victoza 0.6 milligram per 0.1 milliliter pen 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 Tymlos 80 microgram pen injector prescribed for postmenopausal 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 records submitted at the reconsideration level. Your medical records show your doctor prescribed Tymlos to treat your postmenopausal osteoporosis. 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 Tymlos. 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 Naloxone HCL 100% powder prescribed for lichen planopilaris. The Part D plan denied your request. We received a reconsideration 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 records show Naloxone HCL powder is an ingredient of a compounded drug. Bulk powders (i.e., Active Pharmaceutical Ingredients for compounding) does not satisfy the definition of a Part D drug and are not covered by 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 Synthroid 112 microgram tablets. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 10-milligrram capsule to treat failure-to-thrive. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 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. 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

You requested Onetouch verio test strips prescribed 400 per 90 days for the treatment of diabetes. The Part D plan denied your request. We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is not required to cover the Onetouch verio test strips. Medicare rules state drugs that are not considered a medical supply directly associated with the injection of insulin are not covered under Part D. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare 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

You requested a tiering exception for Eliquis 2.5 milligram tablets prescribed for paroxysmal atrial fibrillation. The Part D plan denied your request for a tiering exception because Eliquis is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. We received a reconsideration 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 plan shows Eliquis is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis multidose 0.05 percent eye drops prescribed as directed for dry eye syndrome, and keratoconjunctivitis sicca, not specified as Sjogren's- bilateral. 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. We also researched Medicare systems and reviewed the enrollment data available. Restasis 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 Sildenafil Citrate100 milligram tablets. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read 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 also researched Medicare systems and reviewed the enrollment data available. A request was sent to your prescriber for additional information including the diagnosis that the drug is being prescribed for. We have not received a response. The documentation was insufficient to determine if the drug is prescribed for a medically accepted indication and if the drug is eligible for Part D coverage.  A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clindamycin Phosphate 1 percent solution prescribed twice daily as needed for acne vulgaris. The Part D plan denied your request because the documentation did not support an off-formulary 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. We also researched Medicare systems and reviewed the enrollment data available. 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 Clindamycin Phosphate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage of Desvenlafaxine Succinate ER 50 milligram tablets. The Part D plan denied the request for coverage stating the medication was being prescribed for a non-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. During this review, a prescriber statement was requested and received. We reviewed all documentation submitted.The medical records submitted at reconsideration indicate that Desvenlafaxine Succinate has been prescribed for the treatment of vasomotor symptoms (severe hot flashes) in a postmenopausal enrollee receiving chemotherapy treatment for breast cancer. This is an acceptable use for Desvenlafaxine Succinate outlined in the Medicare approved compendia,However, the plan has prior authorization requirements for the coverage of Desvenlafaxine Succinate, which have not been satisfied. The plan requires that the enrollee has an inadequate treatment response, intolerance, or a contraindication to two of the following: serotonin and norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, Mirtazapine, or Bupropion.While the medical records support that the enrollee has had an inadequate response to a serotonin and norepinephrine reuptake inhibitor, Effexor, the records do not show that the enrollee had an inadequate treatment response, intolerance, or a contraindication to one of the other medications required by the plan. Therefore, the submitted medical records do not support that all of the plans requirements for coverage of this medication have been met. 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 Lamotrigine 200 milligram tablets prescribed for bipolar II disorder. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Lamotrigine is a generic drug on Tier 2 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Repatha Sureclick 140 milligrams/milliliter injection pen prescribed as directed for atherosclerotic heart disease of native coronary artery without angina pectoris, and unspecified hyperlipidemia. The Part D plan denied your request because the documentation did not support an off-formulary 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. We also researched Medicare systems and reviewed the enrollment data available. 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 the Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amitiza 24 microgram capsules prescribed twice a day for constipation. The Part D plan did not provide a timely decision.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 that you have failed Linzess and Lactulose.  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 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 Amitiza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zocor 20 milligram tablet prescribed for hyperlipidemia.  The Part D plan denied the request.  The requested drug is not on the plans formulary. 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 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. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lynparza 150 milligram tablets prescribed to treat metastatic urothelial carcinoma. 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 the doctor prescribed Lynparza to treat metastatic urothelial carcinoma. The enrollee has been treated with chemotherapy and radiation, followed by Opdivo and surgery. Molecular testing showed the enrollee is BRCA positive. The prescriber recommends the use of Lynparza because it has been effective in the treatment of other malignancies for patients who are BRCA positive. The medical literature provided by the prescriber is not from a Medicare approved compendium. The Medicare approved compendia do not support the use of Lynparza for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Lynparza.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nubeqa 300 milligram tablets prescribed to treat metastatic castration resistant prostate cancer. 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 the enrollee was diagnosed with prostate cancer in 2017; the enrollee was treated with surgery and Lupron. The record shows the enrollees prostate-specific antigen levels continued to increase. The imaging results show metastatic disease in the paratracheal and retroperitoneal lymph nodes. The doctor prescribed Nubeqa to treat metastatic castration resistant prostate cancer. The Medicare approved compendia support the use of Nubeqa with Lupron for non-metastatic castration resistant prostate cancer. Medicare approved journals were not provided by the prescriber to support the use of the requested drug for this enrollee. The Medicare approved compendia do not support the use of Nubeqa for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Nubeqa.