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

At issue is a tiering exception request for Flovent HFA 110 microgram inhaler. The Part D plan denied the 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.Flovent HFA is a brand drug on Tier 3 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  Therefore, this drug is not eligible for a tiering exception. In addition, without a diagnosis, reimbursement for the drug purchased cannot be approved.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception or reimburse you for the drug purchased.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 2.5 milligram tablet prescribed as directed for atrial fibrillation. 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 record shows you were prescribed Eliquis to treat your condition. Since the drug isnt on the plans formulary it is not eligible for a tiering exception. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent patch prescribed as directed for chronic back 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. We also researched Medicare systems and reviewed the enrollment data available. 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 drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and  determined that the plan is not required to cover the Lidocaine 5 percent patch.
Appeal type: Prescription Drug
Decision: Favorable

You requested Mekinist 2 milligram tablets prescribed as directed for metastatic pancreatic 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 record shows the enrollee was diagnosed with pancreatic cancer in 2018. The enrollee was previously treated with radiation, surgery, and multiple lines of therapy. Specifically, the enrollee was treated with FOLFIRINOX, as well as Gemcitabine and Abraxane. The enrollee was most recently treated with FOLFIRI, but experienced disease progression. The physician now recommends the use of Mekinist, in combination with Plaquenil, for this enrollee with metastatic pancreatic cancer.The provider submitted an article from the Journal of Clinical Oncology showing a clinical benefit to the use of Mekinist and Plaquenil for patients with similar demographics and treatment history as this enrollee. The National Comprehensive Cancer Network guidelines show that after one to two lines of treatment, there is no standard of care and clinical trial is preferred. As such, the Medicare approved compendia do support the off-label use of this drug for the enrollees condition. In addition, an exception to the plans coverage criteria is medically necessary for this enrollee.A physician reviewed your appeal and determined that the plan is required to cover the Mekinist.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol sulfate 2.5milligrams/3 milliliter nebulizer solution prescribed as directed for asthma. 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Albuterol sulfate nebulizer solution to treat your asthma. However, we determined that the drug is not eligible for Part D coverage. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. Therefore, the drug cannot be considered for payment under the Part D benefit.    A physician reviewed your appeal and determined that the plan is not required to cover Albuterol sulfate nebulizer solution.You may wish to submit a request for Albuterol sulfate nebulizer solution to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dextroamphetamine/Amphetamine 5 milligram tablet to treat excessive daytime drowsiness in an enrollee with idiopathic hypersomnia.  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.The prescriber sent a letter dated 2/26/2021 clarifying the medical history.  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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Topiramate 200 milligram tablets prescribed daily for bipolar 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Topiramate to treat your bipolar disorder. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and determined that the plan is not required to cover the Topiramate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets prescribed three times daily 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 also researched Medicare systems and reviewed the enrollment data available. Your medical records show 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. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and  determined that the plan is not required to cover the Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Avapro 300 milligrams tablets prescribed for the treatment of 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.This drug is being 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 Guanfacine HCL 1 milligram tablets prescribed to treat the diagnosis of 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.Guanfacine HCL is not on the plans formulary. In addition, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees conditions. Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Guanfacine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablets prescribed twice daily for postural orthostatic tachycardia 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 record shows the physician prescribed Corlanor for the treatment of postural orthostatic tachycardia syndrome. 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 Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 200 milligram tablets prescribed for psychophysiologic insomnia. 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. The submitted documentation indicates your doctor prescribed Modafinil for psychophysiologic insomnia. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta 50 milligram tablet prescribed twice daily for pain related to fibromyalgia. 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 records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Nucynta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lipitor 20 milligram tablets prescribed for vascular disorder of intestine. 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 Lipitor for vascular disorder of intestine. The Medicare approved compendia do not support the use of the drug for your condition. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ofev 150 milligram capsule prescribed as directed for chronic fibrosing interstitial lung disease. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration levelThe medical records show you were prescribed Ofev to treat your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has been met. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover Ofev.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle Libre 14 day reader prescribed for type II diabetes mellitus. The Part D plan denied the 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 item at issue is a glucose monitoring device. Glucose monitoring devices are eligible for coverage under Part B. The item is not eligible for Part D coverage.We determined that the plan is not required to cover Freestyle Libre 14 day reader.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 1% gel prescribed for shoulder pain. 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 Diclofenac Sodium gel for shoulder pain. The Medicare approved compendia do not support the use of the drug for your condition. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zonisamide 100 milligram capsules prescribed for paroxysmal dystonia and myoclonus. 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. The submitted documentation indicates your doctor prescribed Zonisamide for paroxysmal dystonia and myoclonus. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cefazolin Sodium 2 grams/20 milliliters prefilled syringe prescribed for staph infection. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.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 Nexlizet 180 milligram/10 milligram tablets. The Part D plan denied the request. We performed an independent and de novo review. To make our decision we reviewed all documentation submitted. This includes any records submitted at the reconsideration level. The plan requires prior authorization criteria be met for this drug to be covered. There are no records showing a confirmed diagnosis of heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease. There are no records showing a low-density lipoprotein cholesterol level above your goal LDL-C despite having an adequate trial of Repatha or indication you have tried Repatha or unable to take Repatha due to previous intolerance or contraindications. The prior authorization requirements were not met. A physician reviewed your appeal and determined that the plan is not required to cover Nexlizet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Quetiapine Fumarate Extended Release 300 milligram tablets prescribed to treat obsessive compulsive disorder, autism, and aggressive behaviors. 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 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 Quetiapine Fumarate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets prescribed for the enrollees condition. 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.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 Lidocaine Ointment 5% prescribed to treat 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. 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 ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armodafinil 250 milligram prescribed for fatigue secondary to multiple sclerosis. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited 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 records 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 does 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 your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Fentanyl Patch 50 microgram/hour prescribed to treat pain due to a stage 4 ulcer not controlled with hydrocodone or tramadol. 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 does not include information that states whether the enrollee is opioid tolerant with stated dosage of the other opioids being used. We requested information from the prescriber but did not receive a response. Medicare compendia criteria for use of the Fentanyl Patch has not been met.A physician reviewed your appeal and determined that the plan is not required to cover Fentanyl Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuedexta 20-10 milligram capsule prescribed as directed to treat pseudobulbar affect. The Part D plan denied the 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. No medical records were provided by the prescriber. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug 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 Nuedexta because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Adapalene 1% cream to treat acne. The Part D plan denied the request. We received an expedited 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.