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

At issue is a tiering exception request for Mesalamine DR 1.2 gram tablets prescribed for ulcerative colitis. 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. Mesalamine DR is a generic drug on Tier 4 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

You requested Budesonide 3 milligram capsule prescribed three capsules daily for non-infective gastroenteritis and 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 documentation shows your doctor prescribed Budesonide to treat your non-infective gastroenteritis and colitis. 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 Budesonide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Oxycodone HCL 20 milligram tablet for an unknown diagnosis. 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. Without a diagnosis, it cannot be established that the Oxycodone HCL is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the Oxycodone HCL 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 Oxycodone HCL.
Appeal type: Prescription Drug
Decision: Favorable

You requested Stivarga 40 milligram tablets prescribed as directed for metastatic rectal 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 medical records show the doctor prescribed Stivarga to treat rectal cancer. The enrollee was initially diagnosed with rectal cancer in 2016, and treated with neoadjuvant Folinic Acid, Fluorouracil, and Oxaliplatin. The enrollee has also been treated with Capecitabine and radiation, as well as Folinic Acid, Fluorouracil, and Irinotecan. However, the enrollee developed severe neuropathy and hand/foot syndrome so the prescriber has requested to change the treatment regimen to Stivarga. The enrollee has progressed through all available regimens, including Irinotecan, Fluorouracil, and Oxaliplatin. The enrollees disease pathology is not MSI-H, so the enrollee is not a candidate for immunotherapy. The enrollees RAS status is unknown so the enrollee cannot received an epidermal growth factor receptor inhibitor. The following citation was referenced in the National Comprehensive Cancer Network, a Medicare approved compendium, and supports the use of this drug for the enrollees condition: Stivarga is recommended as subsequent therapy as a single agent for advanced or metastatic disease not previously treated with Regorafenib, in patients who have progressed through all available regimens besides Regorafenib or Trifluridine/Tipiracil, with or without Bevacizumab.The prior authorization criteria include that the enrollee has experienced disease progression, intolerance, or contraindication with the anti-vascular endothelial growth factor therapy. In this case, the enrollee has a contraindication to anti-vascular endothelial growth factor therapy. Avastin and Ziv-Aflibercept must be used with Fluorouracil, which the enrollee has a contraindication to. The documentation shows the enrollee has satisfied the plans prior authorization criteria.A physician reviewed your appeal and determined that the plan is required to cover Stivarga.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 620 micrograms/2.48 milliliters for subcutaneous injection prescribed as directed 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 records submitted at the reconsideration level. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested. The medical records show the doctor prescribed Forteo to treat osteoporosis. The 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 Forteo. 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 Zarzio 300 milligrams/0.5 milliliters prescribed as directed for leukopenia. 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.Your medical records show your doctor prescribed Zarzio to treat your leukopenia. 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 Zarzio.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Prolia 60 milligram per milliliter syringe for subcutaneous injection prescribed for postmenopausal osteoporosis. 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 Lidocaine 5 percent patch prescribed as directed for primary osteoarthritis of the right shoulder, sacroilitis, not elsewhere classified, cervicalgia, and other chronic 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 Lidocaine 5 percent patch to treat your primary osteoarthritis of the right shoulder, sacroilitis, not elsewhere classified, cervicalgia, and other chronic 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 Lidocaine 5 percent patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 145 microgram capsules prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Linzess is a brand drug on Tier 2 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 Lidocaine 5% patch for personal history of transient ischemic attack and cerebral infarction without residual deficits. 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 to treat your personal history of transient ischemic attack and cerebral infarction without residual deficits. 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 Nulojix 250 milligram solution prescribed following a kidney transplant. The Part D plan denied your request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any other information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The record shows you that your doctor prescribed Nulojix for prevention of transplant rejection following your kidney transplant. According to Medicare records, you were enrolled in Medicare Part A when your kidney transplant was performed on April 20, 2021. Therefore, Nulojix is covered under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law, even if you currently do not have Part B coverage. 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 Reyvow 50 milligram tablets prescribed as directed for acute 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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Reyvow.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Briviact 100 milligram tablets prescribed as three tablets in the morning and two tablets in the evening for seizures. 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 a total of 500 milligrams of Briviact daily to treat seizures; the prescriber requested coverage for 150 tablets per 30 days. However, the Medicare approved compendia do not support the use of this drug in a dosage greater than 200 milligrams daily for the enrollees condition. Therefore, an exception to the plans quantity limit exception cannot be granted.A physician reviewed your appeal and determined that the plan is not required to cover Briviact.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dextroamphetamine/Amphetamine ER 20 milligram capsules as directed for attention deficit hyperactivity 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.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 Dextroamphetamine/Amphetamine ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Epolamine 1.3% topical patches prescribed every 12 hours for rib 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 the doctor prescribed Diclofenac Epolamine to treat rib pain, which developed after a fall. 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 Diclofenac Epolamine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Balsalazide Disodium 750 milligram capsules prescribed as directed for colon inflammation and irritable bowel disease. 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 Balsalazide Disodium to treat your colon inflammation and irritable bowel disease. However, the Medicare approved compendia do not support the use of this drug for your condition. Since the drug has not been approved for coverage, the tiering exception request cannot be considered.A physician reviewed your appeal and determined that the plan is not required to cover Balsalazide Disodium.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zolpidem Tartrate 10 milligram tablets prescribed as directed for narcolepsy. 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 Zolpidem tartrate for an enrollee with narcolepsy. At reconsideration, the prescriber also provided a diagnosis of insomnia. However, the medical records submitted for review do not show a diagnosis of insomnia. It could be determined that the drug was prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover Zolpidem tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nubeqa 300 milligram tablets prescribed as directed for metastatic prostate cancer. The Part D plan denied your request; the plan stated that the prior authorization request could not be approved because the drug was not prescribed for a medically accepted indication. 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 Nubeqa to treat metastatic prostate cancer. The records show the enrollee was initially diagnosed with prostate cancer in 2012. In 2017, the enrollee began androgen deprivation therapy. The enrollee subsequently developed bony disease in 2018. The enrollee started treatment with Xtandi, but was unable to tolerate it and the treatment regimen was changed to Zytiga. The enrollee then required hospitalization for liver problems that developed while taking Zytiga. Currently, the enrollee is being treated with Eliqard. The prescriber has requested for coverage for Nubeqa since the enrollees disease is castrate resistant. The prescriber has not submitted Medicare approved journals supporting the use of this drug for the enrollees conditions. Additionally, the Medicare approved compendia do not support the use of this drug for the enrollees metastatic prostate cancer. A physician reviewed your appeal and determined that the plan is not required to cover Nubeqa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vitamin D 1.25 milligram(50,000 unit) 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. According to Medicare rules, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Vitamin D. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligram/milliliter subcutaneous injection pen 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 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 a request for coverage of Modafinil 100 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 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 Modafinil has been prescribed for the treatment of fatigue related to malignant neoplasm of the brain. 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

You requested Lidocaine 5% patch prescribed one patch daily for osteoarthritis in right shoulder. 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 to treat your osteoarthritis. 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 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Belladonna Alkaloids Opium 16.2-60 milligram rectal suppository prescribed for prostate surgery 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. According to Medicare rules, drugs that are not approved by the Food and Drug Administration are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover or reimburse you for the Belladonna Alkaloids Opium suppository. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patches prescribed for low back pain and rheumatoid arthritis. 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 Lidocaine patches for low back pain and rheumatoid arthritis. 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.